Eltisley Manor

A hand wash station has been provided outside the main entrance to allow all visitors to wash their hands before entering the building

Visitors undertook a rapid COVID -19 test before entry to the building. They were asked to complete a health screening questionnaire and then had their temperature checked. They were then provided with personal protective equipment (PPE). This was in line with government guidance.

People from next week are able to have two designated visitors to enter the building, a visitor's pod was available for other family members. A booking system was in place.

People were able to stay in contact with friends and relatives via facetime and zoom as well as via the telephone. Staff assisted people where required.

The service was clean and there was cleaning in progress throughout our visit.

Staff had received training in, putting on and taking off personal protective equipment (PPE), infection control and COVID-19.

The provider had developed policies, procedures and risks assessments for managing the service in relation to COVID-19.

Eltisley Manor is a care home that provides nursing and personal care to 37 adults and older people. This service caters for people with mental health needs, some of whom also have physical disabilities.

Three of the 37 people live in the Coach House, which is a separate building on the same site, intended as a ‘step-down’ unit for people who are planning to move on to more independent living in the community.

People’s experience of using this service:

•People were happy living at Eltisley Manor because they felt safe and staff looked after them well. Staff enjoyed working at the home and the registered manager and deputy manager provided them with strong leadership.

•There were enough staff to meet people’s needs. New staff underwent a thorough recruitment process so the provider knew they were suitable to work with people living at the home.

•The staff team was committed to providing a high-quality, personalised service and keeping people safe. They had undertaken training in a wide range of topics so they had the skills and knowledge to effectively meet people’s needs. Staff understood their responsibilities to report any concerns.

•People helped to plan their care and support. Staff involved them in assessing risks to themselves and others. Staff supported people to be as independent as possible so that people gained confidence in doing things for themselves. This included taking responsibility for their own medicines, cooking their own meals and learning everyday living skills.

•Staff followed infection prevention and control procedures and staff gave people their medicines safely and as they had been prescribed.

•The kitchen staff made people a choice of nourishing food. People could make their own drinks, with or without staff support, at any time. External healthcare professionals supported people to stay as healthy as possible.

•There were good relationships between people and the staff. Staff knew people well, respected people’s choices and always asked for consent before they carried out any tasks for the person.

•Personalised support plans gave staff clear guidance about how to meet each person’s needs in the way they preferred.

•People had a range of opportunities. They could choose to be involved in paid work in the home, go to college, do voluntary work or follow their own interests.

•The registered manager sought people’s views about the running of the home and put actions in place to make improvements wherever possible. Staff felt involved in the home, supported by the registered manager and said their ideas were listened to.

•The provider had a clear structure in place to monitor the quality of the service, which included regular auditing and visits to the home by the provider’s staff.

More information is in the full report

Rating at last inspection:

At the last inspection we rated this service Good (report published on 10 June 2016).

Why we inspected:

This was a planned inspection based on the previous rating.

Follow up:

We will continue to monitor this service.

Accommodation is provided over two floors. All bedrooms are for single occupancy and there are separate toilet and shower facilities. There are communal areas, including dining rooms and lounges, for people and their guests to use. Eltisley Manor is located in a rural setting near to the town of St Neots.

This inspection was undertaken on 27 April 2016 and 28 April 2016 and was unannounced. The previous inspection was undertaken on 5 March 2015 and we found the provider was in breach of one of the regulations that we assessed. This was in relation to notifications that had not always been sent to the Care Quality Commission. Notifications are information about important events that the provider must tell us about by law. We received an action plan from the provider which detailed the actions that that they were taking to meet this regulation. During this inspection we found that the required improvements had been made.

A registered manager was in post at the time of this inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the home. Like registered providers, they are ‘registered persons’. Registered persons have the legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the home is run.

Staff at Eltisley Manor provided people with safe care and protected them from the risk of harm. People’s medicines were managed and administered by competent staff and people were supported to take their medicines as prescribed.

Risks to people’s health and safety had been assessed and action had been taken to reduce identified risks. Satisfactory recruitment and pre-employment checks were completed so that only suitable staff were employed at the home.

People were involved in the planning and the reviewing of their care as much as possible and care was provided in accordance with their preferences and wishes. Staff had received training so that they were able to safely support people with their mental health care needs. People were supported to maintain their dietary and nutritional needs. Regular contact with health care professionals ensured that people’s needs were discussed, monitored and reviewed

People were supported to access a range of health and social care services to monitor their mental health and physical care needs.

There were respectful and supportive relationships in place between staff and people living in the home and people were treated with respect. People’s rights in making decisions and suggestions in relation to their support and care were valued and acted upon by staff. People had limited access to pursue their individual social hobbies and interests to promote their sense of wellbeing.

The CQC monitors the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that people’s mental capacity was assessed so that their rights were being protected. There were seven DoLS applications in place at the time of this inspection.

Complaints and concerns made to the registered manager and staff were acted upon to satisfactorily meet people’s needs.

Staff felt supported and managed so that they could effectively provide people with support. There were regular meetings in place where people, staff and the registered manager were able to discuss issues and developments in a proactive manner. People and staff told us that there was an open culture within the home and they were able to raise their concerns or issues whenever they wished. Quality audits and monitoring procedures were in place and there were effective actions to address any improvements that were needed.

Two adult social care inspectors carried out this this inspection on 14 August 2014. The focus of the inspection was to answer five key questions: is the service safe, effective, caring, responsive and well-led?

As part of this inspection we spoke with six people who used the service, the interim manager, six members of care staff and four healthcare professionals who had regular contact with the home. We reviewed records relating to the management of the service which included: six care plans, daily records, infection control procedures, medication administration, the maintenance of the premises, training records and quality assurance monitoring records.

Below is a summary of what we found. The summary describes what people who used the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service caring?

People told us that they received consistent and respectful support from care staff and felt able to make choices and changes when required. Staff told us that they were well supported and supervised so that they could provide safe care and support to people. We observed that care staff spoke to people in a friendly and attentive manner and responded quickly to people's care needs.

Is the service responsive?

We saw that people's personal care and social support needs were assessed and mostly being met. This also included people's individual choices and preferences as to how they liked to be supported. People we spoke with told us that they felt well cared for and observations we made during the inspection confirmed that there was a good rapport between people and staff.

Is the service safe?

Risk assessments were in place to ensure that care and support could be safely provided to people living in the home. Care staff understood their roles and responsibilities in making sure people were protected from harm. There were effective safeguarding procedures in place to ensure that people were protected from abuse and harm. We saw that Deprivation of Liberty (DoLs) assessments were carried out where necessary. However, we saw that improvements were needed regarding the safe administration and recording of medication and the assessing and delivery of health care.

Is the service effective?

We found that care staff were knowledgeable about people's individual care and support needs. People that we spoke with confirmed that staff provided consistent and kind support. Care planning documentation was generally well coordinated and reviewed to ensure that individual care and support needs were being met. The interim manager stated that support documentation was regularly audited to ensure it met people's assessed needs. However we noted that some improvements were needed to ensure that people's healthcare needs were being properly met.

Is the service well led?

Staff that we spoke with told us that they felt well supported by the interim manager and senior care team and were regularly trained to safely provide care and support. People that we spoke with told us that they felt they were listened to and support was consistently and safely provided. Quality assurance systems were in place to audit the care and services provided. Surveys were carried out to gather opinions from people living at the home to ensure that ongoing improvements could be made.

Care and support was being regularly reviewed to ensure that peoples' needs were being met. There was evidence of people's involvement in the planning of their care and support.

Nurses were responsible for the safe administration of medication and records of administration were accurately completed.

There was regular staff supervision and ongoing training sessions in place to ensure that staff could safely deliver care and support to people.

The home had an effective system to effectively deal with complaints that people using the service. People regularly had access to staff to resolve any concerns that they had.

There has been a major refurbishment of the home over the last year which has improved the accommodation for people. The home was clean and there were systems in place to ensure appropriate standards of hygiene.

The organisation had recently identified a need to review and update all of the care plans that were in place and this was ongoing at the time of our visit. The quality of care records that we looked at was variable and we have said that improvements need to take place to ensure that risks are appropriately assessed with corresponding care plans in place.