Archived: The Elms Care Home

The Elms is a residential care home providing personal care for up to 13 people. The service provides support to older people, some of whom were living with dementia in one adapted building. At the time of our inspection there were ten people living in the home.

People’s experience of using this service and what we found

People did not always have risks to their safety assessed and planned for. We found where risks were known these had not been reviewed and where health needs had changed these were not reflected in people’s care records.

People did not have their medicines administered safely. People’s medicines administration records were not accurately completed and there was insufficient guidance for staff on how to administer some medicines safely.

People were not supported by enough staff to meet their needs at the times they required. People had to wait for their support and told us they had limited choice about when their care needs were met.

People did not have their individual needs and preferences considered and were not consistently supported to meet their nutrition and hydration needs in line with health professional advice.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The building was not well maintained and clean. There were fire safety concerns which had not been addressed.

Staff were not consistently trained, and their competency was not checked on a regular basis. The provider did not have systems in place to ensure staff were recruited safely.

Governance arrangements in the home did not identify areas for improvement and where concerns had been raised about safety and quality actions had not consistently been taken to make changes to the service and drive improvements.

Rating at last inspection and update

The last rating for this service was requires improvement (published 27/01/2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider had not completed the actions and remained in breach of regulations.

This service has been in Special Measures since 16 December 2020. During this inspection the provider did not demonstrate improvements have been made and the overall rating for this inspection is inadequate and the provider remains in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection and was prompted in part due to concerns received about medicines, governance and staffing. A decision was made for us to follow up on past concerns and examine those risks.

We carried out an unannounced comprehensive inspection of this service on 19 November 2020. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care, staffing levels, recruitment practices, person centred care, mental capacity act application and governance

Please see the action we have told the provider to take at the end of this report. For full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

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

The Elms is a residential care home providing personal care to up to 13 people aged 65 and over. At the time of the inspection nine people were using the service.

People’s experience of using this service and what we found

People’s needs were not always assessed and care planned to enable staff to meet them and mitigate potential risks. This placed people at risk of not consistently receiving safe care and treatment.

People were not effectively safeguarded from potential neglect or abuse as potential safeguarding concerns were not always escalated to the management team or investigated to reduce future risk.

Infection control guidance was not always followed to ensure people were supported to reduce their risk of exposure and transmission of COVID-19.

People were not always supported in a clutter free environment to enable effective cleaning.

People's medicines were not consistently stored or monitored in a safe way.

Quality assurance procedures had not been regularly completed at the service to identify areas of improvement and drive change. This meant improvements required to people's care and treatment had not been identified in a timely way prior to our inspection.

People's feedback was not always acted upon to ensure they received care in line with their preferences.

People were supported by enough safely recruited staff that understood how to keep them safe, and had access to healthcare when required.

Rating at last inspection

The last rating for this service was requires improvement (published 10 April 2020). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and we found further concerns. This meant the provider was still in breach of regulations.

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

Why we inspected

The inspection was prompted in part due to concerns received about the oversight at the service. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

Enforcement

We have found evidence that the provider needs to make improvements. Please refer to the safe and well-led sections of this report. We identified breaches in relation to people not consistently receiving safe care and treatment and audit systems had not been completed to identify and drive improvements at the service.

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Elms is a residential care home providing personal care to up to 13 people aged 65 and over. At the time of the inspection 10 people were using the service.

People’s experience of using this service and what we found

People’s risks were assessed but not always consistently managed, infection control measures were not always followed.

Some recent equipment changes and the layout of bathrooms made it difficult for staff to support people to bathe regularly.

Quality assurance procedures were not always robust enough to make sure changes were made to the service following identified issues.

People were supported by enough safely recruited staff that understood how to keep them safe, and had access to healthcare when required.

People received their medication safely and at the times they needed them.

People’s needs and preferences were assessed and reviewed, and were supported in the least restrictive way possible.

People were supported by kind and caring staff that knew them well and helped them maintain their dignity and independence.

Staff felt the registered manager and provider were approachable and were able to go to them if there were any issues.

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

Rating at last inspection

The last rating for this service was good (published 18 November 2017).

Why we inspected

The inspection was prompted in part due to concerns received about pressure care and infection control. A decision was made for us to inspect and examine those risks.

Enforcement

We have found evidence that the provider needs to make improvements. Please refer to safe, effective and well-led sections of this report. We identified one breach in relation to peoples risks not being managed consistently, and audit systems were not always effective at identifying areas for improvement.

You can see what action we have asked the provider to take at the end of this full report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Elms Care Home is registered to provide accommodation with personal care for up to 13 older people including people with physical disabilities and people living with dementia. On the day of the inspection there were seven people living at the home. 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.

Improvements had been made to the provider’s recruitment processes to ensure staff were safely recruited and were suitable to work with vulnerable people. People received their medicines as prescribed and systems used to manage medicines had been improved to ensure they were safe and effective. There were sufficient numbers staff to meet people’s care and support needs and respond to people when required. Risk management processes had been reviewed to ensure staff received appropriate guidance on how to manage risks associated with people’s safety, health and well-being.

Improvements had been made to the way in which people’s capacity to make decisions had been assessed and recorded. Clear information was now available to staff on how to support people to make their own decisions where possible, or to support decisions being made in the person’s best interests. Since the last inspection changes had also been made to the daily menus and people were now being offered a choice of meals. Snacks were also readily available to people to encourage a healthy nutritional intake. People were supported by staff who had the skills and knowledge to meet their care and support needs. People were supported to access healthcare professionals when they needed to and staff were aware of people’s health needs and how best to support them.

We found improvements had been made to the way people were supported which ensured their dignity and privacy was maintained. People told us staff were kind and caring and we observed caring interactions between people and staff throughout the inspection visit. People were supported to maintain their independence where possible and were involved in decisions about their day to day care and support. Visitors were welcomed and known by staff, who recognised the importance of people maintaining relationships that were important to them.

Improvements had been made to the range of activities available for people to participate in. More detailed information about people’s life histories and interests was available to staff to improve the quality of activities offered. People and their relatives were involved in the planning and reviewing of their care. People knew how to complain if they were unhappy about any aspect of their care and support and there was a system in place to manage complaints.

People, relatives and staff told us they felt the home was well managed. The registered manager and staff team had made a number of improvements since the last inspection. There were effective systems in place to monitor the quality of care being provided. People and staff were involved in identifying further areas for development and this feedback was used to drive improvement. The provider had notified us of incidents and events as required by law.

The Elms is registered to provide accommodation for up to 13 people who require personal care and support. On the day of the inspection there were 12 people living at the home. 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.

The provider had not carried out sufficient checks on new staff members. People, relatives and staff felt there were not enough staff to meet people’s care and support needs in a timely way. People told us they felt safe. People received care from staff that protected them from the risk of potential abuse. Staff were confident in reporting any concerns or suspected abuse. Risks to people were recorded and understood by staff. People were happy with the way they received their medicines, however systems used to manage medicines had not identified discrepancies in the receipt and administration of medicines.

Assessments of people’s capacity to make certain decisions had not always been recorded accurately. People told us they enjoyed the food but were not offered a choice at mealtimes. Staff received regular training and had the skills, knowledge and experience to meet people’s care and support needs. People’s consent was sought before care was provided. Staff were aware of people’s preferences and people with specific dietary requirements received appropriate food. People had access to appropriate healthcare according to their needs and staff responded without delay to changes in people’s health.

People were not always supported in a way that maintained their dignity. Staff knew people well and treated people with kindness. Staff had a good knowledge of people’s needs and preferences. People were involved in making decisions about their care and support. People’s relatives were welcome to visit the home at a time of their choosing.

People told us there was a lack of day to day activities available to them. People’s care was tailored to their individual needs and choices. Staff had a good understanding of people’s preferences and life histories. People felt able to express their views to the staff or the registered manager. There was a system in place to manage complaints.

People and relatives had been invited to give feedback about the service. Staff expressed mixed views about whether they felt listened to when they contributed ideas. The registered manager and senior staff carried out checks to monitor the quality of care provided, however, these audits had not identified the issues found at the inspection.

During this inspection we found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Below is a summary of what we found. The summary is based on our observations during the inspection, observations of people using the service, the staff supporting them and from looking at records. We used the evidence we collected during our inspection to answer the five questions.

Is the service safe?

From our observations and the information we saw in care plans, policies, procedures and audits, the provider's safety monitoring systems were robust. The staff training records showed that staff received regular training on safeguarding. Staff showed they had a clear understanding of their role in providing care and in safeguarding the people they supported. The staff demonstrated that they knew the people well and understood their support needs.

We saw evidence that when people lacked the capacity to make decisions on important areas of their lives, best interests, safeguarding and deprivation of liberty discussions had taken place. We saw the home had the support of the local advocacy service.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. We saw that all the people who lived at the home had a mental capacity assessment and there were no current safeguarding orders in place. The provider was reviewing the safeguarding requirements for all the people who live at the home in the light of the recent changes to the legislation at the time of our inspection.

Staff rotas showed that management had taken people's care needs into account when making decisions about the number of staff required and the skills and experience staff would need. The night time staffing levels and on call system showed that the provider had taken steps to ensure the staffing provision was safe.

We saw where issues of concern had been raised on a previous inspection which related to the storage and audit of medicines kept at the home and risk assessments. These issues had been addressed by the provider and the medicine management and risk assessment systems were safe.

There were systems in place to make sure that management and staff learned from events such as accidents and incidents, complaints, concerns and investigations. This meant that people were benefiting from a service that was taking on board lessons learnt.

Is the service effective?

We saw that people's care needs had been assessed and detailed care plans had recently been reviewed and updated. There was evidence that people and their families were involved in the assessments of their needs and care plan reviews as much as possible.

The staff we spoke with and activity plans we looked at provided evidence that people were supported to maintain active lives.

We saw evidence that people were supported by a wide range of health care professionals. This meant their health and welfare needs were being met.

Is the service caring?

We observed that staff supported each person in a way which met their individual needs. The staff showed warmth, consideration and respect for people. One member of staff we spoke with said, 'I have worked here for many years and I really enjoy my work. I look after people as I would a family member'. Another member of staff said, 'It is a good staff team here, we have worked together for many years and we try to make the place like home for the people who live here'. We saw that staff ensured people's dignity was maintained at all times.

We spoke with one of the people who lived at the home, they said, 'It is as good as it can be here. The girls listen to me, they are lovely'.

The registered manager and staff we spoke with told us they were committed to provide a good caring service to support and look after people. The staff we spoke with demonstrated that they were aware of potential risks, people's rights and their responsibilities.

Is the service responsive?

We saw the care plans and risk assessments had all recently been reviewed and were focused upon the current needs of the individual. The care plans contained detailed information about people's choices and preferences. The information showed that each person had an individual support plan which was adapted regularly to meet their changing needs. We saw that people's health and support plans were regularly updated to reflect people's changing health care needs.

There was evidence of regular support provided from health care professionals. This meant that people's health and welfare was regularly reviewed and monitored.

The staff we spoke with said if they had any concerns, they could always talk with the managers and that they would always listen and address anything they raised. We saw that staff received regular training which equipped them with the knowledge and skills to meet people's support needs.

Is the service well-led?

The home had a clear management structure in place. The provider, registered manager, deputy and the staff we spoke with were very knowledgeable about the people who used the service, changes to legislation and developments in care provision.

We saw on the staff rota that senior staff were on duty to give advice and support. We saw that there were systems in place to provide feedback to staff about changes and developments. The registered manager had ensured that a regular program of staff supervision was in place.

The care people received was reflected in their care plans. One relative told us, 'They get individual attention'.

People were offered nutritious meals and snacks. People we spoke with were complimentary about the food served.

Medication audits and observations of staff administering medications were not undertaken. This meant that any medication errors were less likely to be identified.

We found that there were enough staff to ensure people's needs were met in a timely manner. One relative told us, 'There's always staff in the lounge'.

Records were not always updated to reflect people's latest care needs.

We found that people were supported in making day to day decisions about the care they received. People's values and diversity were respected and promoted.

The care people received was reflected in their care plans and care was delivered in a safe and appropriate way. One relative told us, 'It's lovely in here, people are well looked after'.

Arrangements were in place to ensure that people were protected from harm. People said they felt safe living at the home. Staff demonstrated that they were aware of the importance of safeguarding people from abuse.

We found that staff were recruited in a safe way and correct checks were carried out to ensure their suitability to care for people. Staff were skilled in the provision of care to people. One person told us the home had, 'Very friendly staff. They don't ignore people, they rush to give assistance'.

The service had a clear complaints procedure which was advertised within the home. People told us they would feel confident in raising issues.