Elm Lodge Care Home

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

We were assured the provider was meeting with requirements and nationally recognised government guidance, concerned with the prevention and control of infection, including COVID-19.

People were protected from the risk of harm or abuse within the service. Effective risk management strategies were operated for people's care and related safety needs.

Staff understood people’s individual, risk assessed needs and supported people safely when they provided care. People’s medicines were safely managed, and people received their medicines when they should.

People were supported to have maximum choice and control of their lives. The provider was able to demonstrate that decisions made for people's care and daily living arrangements were lawful, least restrictive and in people's best interests.

Staff were safely recruited, deployed and understood their role and responsibilities for people’s care and safety.

The provider was now able to demonstrate fully embedded and continuous service improvement through effective governance arrangements.

There was a registered manager for the service who understood the requirements of their role. Overall, people, relatives and staff were confident in the management of the service. All were regularly consulted to inform people’s care and the provider’s related service planning and improvement.

Effective partnership working with relevant external professionals and authorities was now demonstrated as fully embedded and sustained for people’s care.

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

The last rating for this service was requires improvement (published 7 September 2019). The provider completed an action plan following the last inspection, to show what they would do and by when to improve. At this inspection we found improvements had been made in the areas we inspected to Good [Safe and Well Led]. The overall service rating remains requires improvement.

Why we inspected

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 COVID-19 and other infection outbreaks effectively.

This was a focused inspection prompted by a review of the information we held about this service, including concerns we received. This report only covers our findings in relation to the Key Questions Safe and Well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Elm Lodge Care Home on our website at www.cqc.org.uk

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

The service had clear visiting protocols in place with robust infection, control and prevention procedures that all visitors were required to follow. This included guidance upon arrival relating to personal protective equipment (PPE), COVID-19 testing and a health screening questionnaire.

The service was regularly cleaned throughout the day. There was cleaning schedules which staff followed, these included regular cleaning of high touch areas.

The service had created accessible information booklets for visitors which detailed the arrangements in place for safe visiting.

Staff received training in relation to infection prevention and control. Staff told us how they managed risks in relation to COVID-19 such as how they took part in regular testing. We observed staff to be wearing the correct PPE throughout our inspection.

We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

About the service

Elm Lodge care home was providing personal care and accommodation over two floors in one adapted building, for up to for 20 older people living with dementia at the time of our inspection. The service can support up to 46 people. The home lies within reach of local community transport and provides single occupancy bedrooms and is designed to enable people to move around safely and independently.

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

Our previous inspections have identified the provider needed to make improvements within the service. Good care is the minimum that people receiving services should expect and deserve to receive. On this inspection we found the provider had made sufficient improvements to be removed out of special measures; however, improvements were still required.

Management systems to monitor and improve the quality, safety and effectiveness of people’s care had now been developed. However, these systems and ongoing care improvements were not yet fully demonstrated or sustained by the provider. Aspects of people’s dementia care needs were not always fully optimised against recognised national guidance and practice standards.

The provider’s management team had begun to develop and embed formalised engagement and partnership working strategies; to help ensure informed, consistent care delivery in people’s best interests. The provider was now meeting their legal obligations and also the conditions of their registration. The nominated individual and registered manager, who were appointed since our last inspection were visible at the service. Overall, staff, people using the service and others with an interest there were now more confident in the management and running of the service. The provider now needs to demonstrate ongoing and sustained governance and service improvement.

Improvements were made for people’s safety and to monitor, act and ensure lessons learned when things went wrong at the service. Revised risk management, staffing, safeguarding and medicines systems and for environmental cleanliness and safety, were mostly sufficient to ensure people’s safety. The provider now needs to demonstrate ongoing and sustained care and service improvement. We made one recommendation in relation to the environment, to further ensure people’s safety and best practice.

Revised care systems and related staff training measures had improved the effectiveness of people’s care. Staff were now more confident in the revised arrangements for their training and support. However, the provider's assured management plan for staff training and support was not yet fully completed, embedded or demonstrated as ongoing.

Staff now understood and followed people’s care plans, which were now accurately recorded and reviewed when needed for people’s care. Improved consultation with relevant external health professionals involved in people’s care was now established and demonstrated. This helped to ensure people received consistent, informed and timely care, to enable them to maintain or improve their health when needed. The provider now needs to demonstrate and ensure this in an ongoing and sustained manner.

People were mostly supported to have maximum choice and control of their lives and staff mostly supported people in the least restrictive way possible. However, related policy and systems did not always fully ensure this or support people’s choice, control and inclusion.

Accessible information was not fully considered or ensured to meet people’s communication needs; and to optimise their choice and understanding for their care and daily living arrangements at the service.

Work was in progress to support the planning of personalised care to meet people’s, needs, preferences and interests. People were supported to engage in home life and with family and friends who were important to them. Social and recreational activities were regularly organised but the arrangements for this did not always optimise or ensure people’s inclusion and choice. Therefore, related improvements were not always fully assured or embedded for people’s care.

People were supported to eat and drink foods they usually enjoyed, and which met their dietary requirements. People’s mealtime experience was not always organised to meet with their individual choices and best interests.

The home was designed and mostly equipped, to enable people to move around independently and safely. Work was in progress to redecorate and further adapt the environment to meet people’s independence, orientation and recognition needs. Interim arrangements meant access to communal lounge and dining spaces was restricted.

People were treated with respect by staff who were kind, caring and mostly ensured their dignity. People were relaxed and comfortable with staff and the management team and felt staff took good care of them. People, staff and told us that they thought the management team were responsive and they now dealt with any concerns promptly.

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

Rating at last inspection and update

The last rating for this service was inadequate (report published 20 February 2019). There were multiple breaches of regulation. This service has been in Special Measures since December 2018. The provider completed an action plan after the last inspection to show what they would do and by when to improve. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures and the provider was no longer in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe, effective, caring, responsive and well led sections of this report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Elm Lodge Care Home on our website at www.cqc.org.uk.

We will continue to monitor the service and 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.

Elm Lodge Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission [CQC] regulates both the premises and the care provided, and both were looked at during this inspection. Single use accommodation and personal care is provided at this service in one adapted building over two floors, for up to 46 older people who may be living with dementia. Both floors of the building provide a dining room and two communal lounges. A secure garden area provided level access for people. At the time of our inspection there were 30 people using the service. All were older adults living with dementia, including many with other chronic health conditions, and some with sensory physical disability needs.

There was no registered manager for the service since November 2018. A registered manager is a person who has registered with the CQC to manage the regulated activities provided at the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements of the Health and Social Care Act (HSCA) 2008 and associated Regulations about how the service is run.

At our previous inspection in January 2018, we rated the service as Requires Improvement for the third consecutive time. People were not always protected from risks associated with unsafe, ineffective or inappropriate care that did not meet with their needs and preferences. The provider also did not operate effective governance systems at the service to consistently ensure the quality and safety of people’s care. These were respective breaches of Regulations 9 and 17 of the HSCA 2008 (Regulated Activities) Regulations 2014. We asked the provider to send us a written report, to tell us what action they were taking to make the improvement required to rectify the breaches and to improve the service to a rating of a least Good. At this inspection we found these improvements were not made.

The provider did not operate effective systems for governance and oversight of the service, or demonstrate lessons learned when required, to ensure the quality and safety of people’s care at the service. Pro-active, sustained and ongoing care and service improvement was not consistently ensured for people’s health and welfare.

The provider did not always tell us or others with an interest in people’s care when things went wrong at the service; or regularly consult with relevant parties help inform or improve people’s care.

Records relating to people’s welfare and the management of the service were not accurately maintained. National guidance was not always followed or reviewed for people’s care.

People who could tell us felt generally safe at the service. People’s safety was not consistently ensured. Risks to people’s safety were not always effectively accounted for, managed or mitigated and people’s medicines were not always safely managed.

There were not always enough staff to provide people’s care and staff were not always safely recruited. The provider’s subsequent improvement actions, which helped to mitigate the risk to people from unsafe staffing arrangements, needed to be demonstrated as continued and sustained.

Staff were trained and generally knew how to recognise and report abuse. Staff and management did not always recognise or act on discriminatory practice, to fully ensure people’s rights, needs and choices in their care.

The service was mostly clean and hygienic but this was not consistently ensured, to fully protect people from the risk of an acquired health infection through cross contamination. A number of environmental adaptations helped to support people’s independence and orientation needs, but this was not fully considered or optimised for people’s benefit.

People did not always receive effective or accurately informed care, which met their needs and preferences and for their wellbeing. The provider’s staffing, communication and care plan record keeping systems were not effective to consistently ensure this. e

Staff felt they received the training they needed but people’s care was not always provided in line with national legislation, standards or guidance. Staff often followed the Mental Capacity Act when required. Where people were subject to any Deprivation of Liberty Safeguards, the provider did not always ensure staff followed any related conditions specified for people’s care in their best interests.

People felt overall, staff were kind, caring and had good relationships with them, which we often saw. Staff’s capacity to consistently ensure people’s equality, rights, choice, comfort and independence were often compromised by the provider’s ineffective care management, communication and staffing systems.

People’s care was organised in a task orientated way and was not always person centred, timely, or appropriate to people’s needs and preferences. The Accessible Information Standard was not fully considered to ensure this was met to benefit people living at the service

People were often confident to raise concerns if they needed to. Concerns and complaints were not always effectively accounted for, or used to inform or make care improvements when needed.

Nationally recognised standards concerned with end of life care were not formally sought, implemented or understood; to best inform people’s care and to ensure their dignity, comfort and choice, when required at the end stage of life.

The service was not well led. Staff were not consistently informed or supported to help ensure people’s care was consistently safe, effective, caring or responsive. Staff, external authorities and health professionals concerned with people’s care at the service, were positive about the new acting manager, who they felt was trying to make a difference. However, confidence in provider and senior management to make the required care improvements was low.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This included two new breaches and two repeated breaches from our previous inspection in January 2018. 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.

The overall rating for this service is 'Inadequate' and the service is therefore 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

We inspected this service on 26 January 2017 and the inspection was unannounced. Elm Lodge is registered to accommodate 46 people in one adapted building and support is provided over two floors. Both floors had a dining room and two communal lounges. A secure garden area was available that people could access. At the time of our inspection 41 people were using the service.

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.

At the previous inspection on the 23 June 2016 the provider was meeting the regulations that we checked but further improvements were needed in the quality of people's care. We rated the safe, responsive and well led domain as requires improvement and the overall rating for the service was Requires Improvement.

At this inspection we found improvements had been made in the safe domain, but improvements in the responsive and well led domain were needed. This is the third consecutive time the service has been rated overall as 'Requires Improvement'. Providers should be aiming to achieve and sustain a rating of 'Good' or 'Outstanding'. Good care is the minimum that people receiving services should expect and deserve to receive and we found the systems in place to ensure improvements were made and sustained were not effective.

The improvements we asked the provider to make at the last inspection, to ensure people were offered a consistent programme of activities that met their needs had not been achieved. We identified that the activities available at the last inspection were reliant on the availability of the activities coordinator. At this inspection the lack of a specific person to provide activities meant that people were receiving fewer activities than they were at our last visit. This was because the provider had not made sufficient alternative arrangements to ensure people were provided with activities on a consistent basis. Although the majority of records looked at were up to date, some were not and didn’t reflect people’s current care needs. This demonstrated that the systems in place to monitor the service and identify where improvements were needed were not effective.

Staff understood their role to protect people from the risk of harm and understood their responsibilities to raise concerns. Individual risks to people and environmental risks were identified and minimised to maintain people’s safety. Assistive technology was in place to support people to keep safe. Systems were in place to prevent and control the risk of infection.

People were protected against the risk of abuse, as checks were made to confirm staff were of good character. There was a sufficient skill mix of staff available to meet people’s care needs. Medicines were managed safely and people were supported as needed to take their medicine as prescribed and access healthcare services.

People were consulted regarding their preferences and interests and the staff team knew people well. People were supported by staff that were trained and they were supported with their dietary needs and to access healthcare services to maintain good health.

People were supported to have maximum choice and control of their lives and staff understood the importance of gaining people’s consent regarding the support they received. The policies and systems in the service supported this practice.

People's rights to privacy and dignity were respected and they were supported to maintain relationships with people that were important to them. People’s representatives were involved the assessment and development of their care plans. There were processes in place for people to raise any complaints and express their views and opinions about the service provided.

Visitors were welcomed at any time. People and their relatives knew who the registered manager was and they were involved in developing the service; which promoted an open and inclusive culture. The provider and registered manager understood their legal responsibilities and staff were supported by the registered manager to enable them to fulfil their role.

We found breaches 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.

Elm Lodge Care Home provides accommodation and personal care for up to 40 older people living with dementia. At the time of our visit, there were 32 people living at the service. There was a registered manager at this 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.

At our last inspection of the service in July 2015 we found the provider’s arrangements to obtain consent for people’s care, for staffing and cleanliness at the service and for effective governance were not sufficient to ensure that people received safe and effective care. These were respective breaches of Regulations 11, 18, 12 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014. Following that inspection the provider told us about the action they were taking to rectify the breaches. At this inspection, we found that improvements were made were sufficient to rectify the breaches but further improvements were needed in the quality of people’s care.

Significant improvements were made to the provider's arrangements for the management and oversight of the service and to check the quality and safety of people’s care. Additional improvements were planned from this which helped to protect people against the risk of unsafe or ineffective care and treatment. Further improvements were needed in relation to the quality, approach and timeliness of people’s care and to demonstrate the provider’s ability to sustain continuous service improvement.

People, relatives and relevant external authorities had increased confidence in the management of the service. The registered manager told us about important events that happened at the service when required. Staff generally understood their role and responsibilities for people’s care. They knew how and were confident to report any significant incidents or changes relating to people’s health or safety needs. Improvements to ensure a more thorough and consistent approach to staff supervision arrangements were in progress.

Staffing arrangements were mostly sufficient to provide people’s care. However, senior staff did not always have time to supervise staff and monitor people’s care, which meant that people did not always receive timely care and support. The provider’s action to recruit additional senior care and provide additional care staff at busier times of the day, helped to mitigate the risk to people’s safety from insufficient staffing arrangements.

The home was generally kept clean and odour free. Systems improvements had been made for infection control, prevention and cleanliness at the service, but staff did not always follow safe practice to ensure this. Further improvements were identified through the provider’s revised management checks in relation to cleaning records, staff practice and use of personal protective equipment. This helped to protect people from the risk of acquiring a health associated infection.

The service ensured people’s rights and best interests by working within the principles of the Mental Capacity Act (MCA) to obtain people’s consent or appropriate authorisation for their care.

The provider’s safeguarding and staff recruitment procedures helped to protect people from the risk of harm and abuse. Information from visiting professionals and the provider showed that staff did not always follow people’s care plans to support people safely when they provided care. The provider’s action plan to address this with staff helped to protect people from unsafe care.

People’s medicines were safely managed but not consistently recorded. Improvements were identified and planned from the provider’s management checks to ensure accurate record keeping for people’s medicines.

Emergency planning, care equipment and environmental servicing and maintenance arrangements helped to ensure people’s safety at the service. The local fire authority’s report of their visit to the service in June 2016 showed that satisfactory fire safety improvements had been maintained at the service.

People were supported to maintain and improve their health and nutrition. People were supported to access external health professionals when they needed to and staff followed their instructions for people’s care.

People were positive about the food provided; they enjoyed their meals and were appropriately supported to eat and drink sufficient amounts. The registered manager agreed measures to develop catering staffs knowledge of specialist diets to improve and enhance people’s dietary experience.

Staff were mostly trained and supported to perform their role and responsibilities. Additional bespoke staff training was identified and planned to improve and enhance people’s dementia care experience and positive behaviour support. The registered provider agreed to review care apprentices’ support arrangements against recognised government guidelines for this.

People were appreciative of staff who were caring, respectful and promoted people’s dignity, privacy and rights when they provided care. Staff often ensured people’s independence, known wishes and choices for their care and they supported people’s contact and appropriate involvement with family, friends and others who were important to them.

People’s care was not always consistently provided in a timely, observant or personalised manner. People were not consistently supported to engage in meaningful social and recreational activities and participate in home life at the service.

Some improvements were made to the décor and environment to aid people’s mood, orientation and recognition around the service; but these were not fully considered and did not consistently support people in this way.

People were informed and knew how to make a complaint or raise any concerns they may have about the service. Complaints were recorded and accounted for, but people were not always satisfied with the way their complaints were handled and or responded to.

Is the service safe?

People were cared for in an environment that was safe, clean and hygienic. Staff had a good understanding of the needs of people living in the home. They were able to describe people's individual needs and what care they required. We saw that people's needs were assessed and care and treatment was planned in line with their individual care plan.

We saw from staff training records that most had received training in safeguarding vulnerable adults. Staff we spoke with knew how to recognise the different types of abuse and how to report any suspicion or the witnessed abuse of any person using the service.

We saw that some people had had assessments for mental capacity and that families were involved in decision making when people did not have capacity.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes to ensure that proper legal processes are in place if a person lacks capacity to make decisions and their liberty is restricted in some way. While no applications had needed to be submitted, proper policies and procedures were in place for this. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service effective?

We spoke with six people who used the service. They told us that they were given choices about how they spent their days. One person said 'It's lovely. I play games. I enjoy living here.' Two other people said, 'They look after me well", and 'Staff, are all nice; I have my own key to my room and I am able to go out with my family.'

Is the service caring?

Two people we spoke with said they were happy with the care they received. We spoke with three members of staff who gave examples of how they treated people with dignity and respect and involved people in their care. We observed staff speaking with people in a kind and caring manner and found that people were comfortable in the presence of staff. We spoke with two family members who said they were very happy with the care provided. One family member said 'She seems very happy here and they look after her well'.

Is the service responsive?

During our visit we looked at five people's care plan records. Each contained assessments of people's individual needs. For example, for their mobility, personal care such as hygiene and dressing, nutrition and continence needs. We saw that any risks to people's safety were determined and care was planned to mitigate any risks that were identified. These included risks from pressure sores, inadequate nutrition and falls. We saw that all risk assessments had been reviewed and were up to date. We saw that healthcare professionals were involved in people's care and treatment where required.

Is the service well led?

The home carried out a quality assurance survey which was sent to people's families. We saw from the response that families were happy with the care. We saw that audits were carried out across areas such as infection control, medication, food hygiene and care plans. The audits we saw demonstrated that good standards of care were in place.

We found that people who used the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. We saw that the provider and the manager held regular meetings with people and their families.

From reading people's care records, we found that, where they were unable to make informed choices about important life decisions their best interests were being fully considered.

We found that attention was given to people's comfort while being moved in wheel chairs. Also, systems were in place to ensure that people received their own clothes after laundering.

People told us that staff talked things over with them before carrying out their care and asked for their consent before decisions regarding their treatment. However, from reading people's care records, we found that where people were unable to make informed choices about important life decisions their best interests were not always being fully considered.

The people we spoke with told us that staff respected their personal preferences and they thought that their needs were met. One relative told us, 'Staff allow [my relative] to have a lie-in some mornings at [my relative's] request.' However, people told us that personal clothes went missing. We observed one person being moved in a way that could cause them discomfort.

People told us that the food provided was, 'very good', and we found that, generally, people's nutritional needs were being met.

People thought that staff were well trained to meet their needs and records confirmed that most staff were up to date with relevant training.