Elizabeth House

Elizabeth House is a residential care home providing personal care to up to 108 people. The service provides support to older people, some of whom are living with dementia. At the time of our inspection there were 107 people using the service.

Elizabeth House accommodates people across two units, Poppy and Bluebell.

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

People were not always supported by enough staff. Some people’s care plans did not include all risks to them or did not include enough guidance for staff. People were supported by trained staff to take their medicines; as and when required medicines were not always administered correctly.

Infection prevention control measures were effective, and the registered manager shared learning from incidents.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The registered manager had processes to monitor the quality of the service. People and staff told us they found the registered manager approachable and supportive. People and staff’s feedback were sought through meetings and surveys. The manager worked effectively with other professionals to support people to access healthcare services.

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 10 March 2020).

Why we inspected

We received concerns regarding incidents involving residents with behaviour support needs. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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.

The overall rating for the service has remained good based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe section of this full report.

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

Recommendations

We have made a recommendation relating to risk assessments.

Elizabeth House is a residential care home providing personal and nursing care to 64 people aged 65 and over at the time of the inspection. The service can support up to 108 people in one adapted building. Elizabeth House accommodates people across two units, Poppy and Bluebell.

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

People told us they were safe and had no concerns about their safety whilst living at Elizabeth House. Suitable arrangements were in place to protect people from abuse and avoidable harm. Staff understood how to raise concerns and knew what to do to safeguard people. Risks to people’s safety and wellbeing were assessed, recorded and followed by staff. Prior to our inspection concerns were raised about staffs’ moving and handling practice. No concerns were observed during this inspection. Suitable arrangements were in place to ensure people received their medication as they should. Enough numbers of staff were available to support people living at Elizabeth House and to meet their needs in a timely manner. Staff recruitment and selection practices and procedures were safe. People were protected by the prevention and control of infection. Findings from this inspection showed lessons had been learned and improvements made since January 2019.

Suitable arrangements were in place to ensure staff were trained and newly appointed staff received a robust induction. Staff felt valued and supported by the registered manager and senior management team and received formal supervision and an annual appraisal. The dining experience for people was good and ensured people received enough food and drink to meet their needs. People were supported to access healthcare services and receive ongoing healthcare support. The service worked with other organisations to enable people to receive effective care and support. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. Since our last inspection to the service in January 2019, many areas of the home environment had been refurbished and redecorated.

People and those acting on their behalf told us they were treated with care, kindness, respect and dignity. Staff had a good rapport and relationship with the people they supported, and observations demonstrated what people told us.

People’s care and support needs were documented, and staff had a good understanding and knowledge of these and the care to be delivered. Information relating to people’s palliative care and end of life care needs was recorded and included peoples and relatives’ preferences and wishes. Suitable arrangements were in place to enable people to participate in meaningful social activities to meet their needs. Complaints were well managed and a record of compliments to capture the service’s achievements was maintained.

People told us the service was well-led and managed. Quality assurance arrangements enabled the provider and registered manager to monitor the quality of the service provided and staff performance. People’s comments about the management team were positive.

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 ‘Requires Improvement’ [published February 2019].

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 improvements had been made.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Elizabeth House is a residential care home that provides personal and nursing care to for up to 108 people aged 65 and over. At the time of the inspection there were 59 people living at the service.

Rating at last inspection:

The rating of the service was ‘Inadequate’ (Last report published 14 September 2018) and the service was placed into ‘Special Measures’. This is where the care expected falls below this standard and is judged to be inadequate. The service is kept under review and is inspected again within six months. We identified five breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014. This related to the level of care people received, risk and medicines management, staffing levels, staff training, induction and supervision; and governance.

Why we inspected:

This was a planned inspection based on the rating at the last inspection of ‘Inadequate’.

People’s experience of using this service:

Significant improvements were noted since our last inspection to Elizabeth House in July 2018. Although people’s comments about the care provided was variable, our observations relating to the level of care people received was much improved. The atmosphere within the service was relaxed and calm. Staff told us the support they received from the registered manager and other senior management team members was much better and they were valued and supported. The registered manager and other senior management team members were visible within the service, were clear about their roles and responsibilities and aware that further improvements were still required.

Risks for people were identified but staff did not clearly record how risks to people’s safety and wellbeing were to be reduced and the actions required to keep people safe. Some people were at risk of having their safety compromised. This was because people who were at risk of swallowing difficulties and choking were not being properly supported.

Care planning arrangements did not ensure all of a person’s care needs were recorded. Staff were aware of people’s end of life care needs but these were not recorded. People enjoyed the activities provided but stated there were occasions when they were bored and there was nothing for them to do. Improvements were required to ensure people who remained in their bedroom were not socially isolated.

People told us staff did not always have sufficient time to give them the care and support they needed. The deployment of staff during the inspection was appropriate and there were enough staff to meet people’s needs.

Staff received regular training opportunities to enable them to meet people’s needs. Newly employed staff received a comprehensive induction and staff told us they felt valued and supported. Recruitment arrangements were robust to ensure the right staff were recruited.

People were protected by the provider’s prevention and control of infection procedures.

Sufficient food and drink was available to people throughout the day. Regular monitoring and review was carried out for people at nutritional risk to ensure their dietary needs could be met.

People experienced positive outcomes regarding their health and wellbeing and had access to healthcare services. The service worked collaboratively with other services and agencies.

People’s capacity to make day-to-day decisions had been considered and assessed and the provider was working within the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Follow up:

We will continue to monitor intelligence we receive about the service until we visit again in line with our inspection programme and scheduling. If any concerning information is received we may inspect sooner.

Our previous comprehensive inspection to the service was on 11 and 19 December 2017, 9 and 18 January 2018. The overall rating of the service at that time was judged to be ‘Good’. A focused inspection was completed on 9 and 10 April 2018 to review the domains of ‘Safe’, ‘Effective’ and ‘Well-Led’. The inspection was prompted in part by a specific incident. ‘Safe’ was judged as ‘Requires Improvement’ and ‘Effective’ and ‘Well-Led’ were judged as ‘Good’. No breaches of regulation were highlighted.

This inspection was completed on 26, 27, 28, 30 July 2018 and 7 August 2018 and was unannounced. There were 100 people living at the service.

We took urgent action to restrict admissions to the service and placed several conditions on the provider's registration because we were concerned about people's immediate safety.

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.

Since our last inspection in April 2018 and following a serious incident at the service in July 2018, the registered manager had resigned. Following their resignation, the registered provider made the decision for an existing registered manager from within the organisation to manage Elizabeth House. 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.’ The registered manager has applied to be registered at Elizabeth House.

Quality assurance checks and audits carried out by the registered provider and former registered manager were not robust, as they did not identify the issues we identified during our inspection and had not identified where people were placed at risk of harm and where their health and wellbeing was compromised. The registered provider and management team of the service had not taken appropriate steps to ensure they had sufficient oversight of the service which ensured people received safe care and treatment. The lack of managerial oversight had impacted on people, staff and the quality of care provided and they were unable to demonstrate where improvements to the service were needed, how these had been addressed; and lessons learned to ensure compliance with regulatory requirements and the fundamental standards.

Significant Improvements were required to ensure sufficient numbers of staff were effectively deployed to ensure people’s individual care and support needs were met in a timely manner and the care provided was ‘person-centred’ rather than ‘service-led’. Substantial improvements were required to ensure people received their prescribed medication as they should and medication practices and procedures were robust. Improvements were needed by the management team to respond to and help manage infections.

The standard of record keeping was poor and care records were not accurately maintained to ensure staff were provided with clear up to date information which reflected people’s current care and support needs. Suitable control measures were not always put in place to mitigate risks or potential risk of harm for people using the service as steps to ensure people and others health and safety were not always considered, and risk assessments had not been developed for all areas of identified risk. People were at risk of harm due to poor manual handling practices by some members of staff.

Although appropriate recruitment procedures were in place to check staffs’ suitability to work with vulnerable people before they started work, improvements were required to make sure these were robustly completed for all prospective staff to ensure safer recruitment practices.

Not all staff had received a robust induction and the role of senior members of staff was not effective in monitoring staff’s practice and providing sufficient guidance and support. Training and development was not sufficient in some areas to demonstrate that people's care and support needs were fully understood by staff and embedded in their everyday practice. Staff had not received regular supervision or an annual appraisal of their overall performance.

The registered provider and management team had not ensured the service was being run in a manner that promoted a caring and respectful culture. Although some staff were attentive and caring in their interactions with people using the service, we observed some interactions which were not respectful or caring and failed to ensure people were treated with respect and dignity.

Although people’s capacity to make decisions had been assessed, 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; the policies and systems in the service do not support this practice.

Not all of a person’s care and support needs had been identified and documented. Improvements were required to ensure that the care plans for people who could be anxious or distressed, considered the reasons for them becoming anxious and the steps staff should take to comfort and reassure them.

People were supported to have enough to eat and drink, however improvements were required to demonstrate people living at the service had received sufficient nutrition and hydration. People were supported to maintain good healthcare and have access to healthcare services as and when required.

Staff were aware of their responsibilities regarding safeguarding people from abuse and knew how to report concerns. People were supported to maintain relationships with people who were important to them.

We have made a recommendation about record keeping relating to people’s nutritional and hydration needs.

Elizabeth House is a care registered to provide care for up to 107 residents, some of whom may be living with dementia. On the day of our inspection 95 people were living at the service.

The service was last inspected in December 2017 and was rated overall good. We undertook this inspection in response to concerns raised about people’s safety. This was a focussed inspection to review safe, effective and well-led. No risks, concerns or significant improvement were identified in the remaining Key Questions through our on-going monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Elizabeth House provides care to people on four separate units within one large building over two floors.

The service has a registered manager. 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.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. Staff assessed risk to people and put plans in place to keep people safe. Some risk assessments needed to be more detailed on how to support people. Staffing levels needed to be consistently maintained to ensure people had prompt support with their needs. People were cared for safely by staff that had been recruited and employed after appropriate checks had been completed. Medication practices were safe and dispensed by staff who had received training to do so. There were systems in place to minimise the risk of infection and to learn from accidents and incidents.

People were safeguarded from the potential of harm and their freedoms protected. Staff were provided with training in safeguarding adults from abuse, Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice.

People had sufficient amounts to eat and drink to ensure that their dietary and nutritional needs were met. The service worked well with other professionals to ensure that people's health needs were met. People's care records showed that, where appropriate, support and guidance was sought from health care professionals, including a doctor, district nurse and speech and language therapist. The environment was appropriately designed and adapted to meet people’s needs.

The registered manager had a number of ways of gathering people’s views; they held regular meetings with people and their relatives and used questionnaires to gain feedback. The registered manager carried out quality monitoring to help ensure the service was running effectively and worked in partnership with other stakeholders to continually improve care.

Elizabeth House is a ‘care home’. People in care homes receive accommodation and or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and we looked at both during this inspection. The service is registered to care for up to 108 older people, some of whom may be living with dementia, a physical disability and/or a sensory impairment. The service does not provide nursing care. There were 107 people living in the service when we inspected.

There was 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.

People received safe care and support. Staff had a good understanding of how to protect people from the risk of harm. They had been trained and knew how to support people with their mobility needs and what to do in an emergency. There were sufficient staff that had been appropriately recruited to ensure they were suitable to work with vulnerable people. The medication system and practice was good and ensured that people received their medication as prescribed. Staff had received training in infection control and knew to wear protection clothing. The environment was clean, safe and hygienic.

People’s care and support needs had been fully assessed to ensure their diverse needs could be met. They, together with their families had been fully involved in the process and people's care plans had been regularly reviewed. Staff knew the people they cared for well, were well trained and supported and knew how to provide effective care.

People received the support they needed with food and drink. They were offered a good choice of meals and were supported to eat healthily. Staff helped people with their healthcare needs and worked together with other professionals to ensure that people received appropriate healthcare.

The service worked in line with other legislation such as the Mental Capacity Act 2005 (MCA) to ensure that people had as much choice and control over their lives as possible. People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice

People were cared for by staff who were kind, caring and respectful. They told us they felt they mattered and staff listened to them. Staff demonstrated a good knowledge of the people they cared for. People and their families were kept actively involved in their care and support. Advocacy services were available if people needed them. An advocate supports a person to have an independent voice and enables them to express their views when they are unable to do so for themselves.

People received personalised care that was tailored to their individual needs and kept under review to ensure it reflected any changes. The service offered people a range of activities both in the service and out in the local community. People were encouraged and supported to maintain their personal relationships with family and friends. The registered manager supported people in using technology such as computer tablets and mobile phones. They told us of their plans to introduce SKYPE so that people could see their loved one when talking with them.

People and their relatives told us they were able to raise concerns and complaints with staff and management. They felt their complaints were listened to and acted upon. Complaints had been fully investigated and actions had been taken to prevent a re-occurrence. Concerns and complaints were discussed at staff meetings to ensure that lessons were learnt. People had end of life plans in place and staff were aware of how to support their families and other people at these times.

The management team valued and supported staff and worked well in partnership with other professionals. There were effective quality assurance systems in place to identify and improve the service.

Following our inspection we received some information for concern. We requested a response from the provider to tell us what actions they were taking to ensure people remained safe and continued to receive a good service. The provider sent an immediate detailed action plan to us to tell us what they were doing to address any identified shortfalls and we continue to monitor the service. Should risk escalate or any further concerns come to our attention, we will inspect again to ensure people are receiving effective and well led care. In the meantime the Local Authority is also working closely with the service.

Further information is in the detailed findings below.

The service provides care and support for up to 108 people some of whom may be living with dementia. There were 107 people living in the service on the first day of our inspection.

At the last inspection in July 2015 we asked the provider to take action to make improvements to staffing levels and to ensure that people were treated with dignity and respect. We had concerns about the lack of towels, flannels and crockery which led to people not being treated with dignity and respect. At this inspection we found that improvements had been made and that staffing levels had improved and there were sufficient supplies of towels, flannels and crockery.

There was a manager in post who was in the process of applying to be registered with CQC. 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.

People received their care and support in a way that ensured their safety and welfare. There were now sufficient numbers of staff who had been safely recruited, were well trained and supported to meet people’s assessed needs. People received their medication as prescribed and there were safe systems in place for receiving, administering and disposing of medicines.

The manager and staff had a good understanding of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and had made appropriate applications when needed.

Staff knew how to protect people from the risk of harm. They had been trained in safeguarding people and had access to guidance and information to support them with the process. Risks to people’s health and safety had been assessed and the service had care plans and risk assessments in place to ensure people were cared for safely.

People had sufficient amounts to eat and drink to meet their needs and individual preferences. Their healthcare needs were monitored and staff sought advice and guidance from healthcare professionals when required. People’s care needs had been fully assessed and their care plans provided staff with the information needed to meet their needs and to care for them safely.

Staff knew the people they cared for well and were kind and caring towards them. They ensured that people’s privacy and dignity was maintained at all times. People participated in activities of their choosing and were encouraged and supported to express their views and opinions. People were able to receive their visitors at any time and their families and friends were made to feel welcome.

People were confident that their concerns or complaints would be listened to and acted upon. There was an effective system in place to assess and monitor the quality of the service and to drive improvements.

During our inspection we spoke with eight people who used the service and several relatives. We also spoke with 12 staff members and the deputy manager.

We looked at 11 people's care records. We also looked at the provider's arrangements for obtaining, and acting in accordance with, the consent to care and treatment for people who used the service. In addition, we looked at medication practices and procedures, the provider's arrangements to ensure people who used the service received sufficient nutrition and hydration, staffing levels and; the provider's arrangements to monitor the quality of the service provided.

Observations of the provider's arrangements in relation to dignity, privacy, respect and the delivery of care for people living at Elizabeth House were undertaken within both units.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

People told us that they liked living in the service and felt safe.

People's privacy, dignity and independence were respected. However, we found that people's views and experiences were not always taken into account in the way the service was provided and delivered in relation to their care. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to respecting and involving people who used the service.

Where people did not have the capacity to consent, the provider had not acted in accordance with legal requirements. We found that not everyone had had their capacity to make day-to-day decisions assessed. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to consent to care and treatment.

We found that people who used the service were protected against the risks associated with the unsafe use and management of medicines.

The provider was not able to demonstrate that there were sufficient numbers of staff available for the needs of the people living at Elizabeth House. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to staffing.

Is the service effective?

Appropriate arrangements were in place to ensure that people who used the service received regular support and access from a variety of health and social care services and professionals.

We found that people who used the service were supported to have adequate nutrition and hydration.

Is the service caring?

People told us that they received the care they needed. People told us that they were happy living at Elizabeth House.

People who used the service had a care plan in place which detailed their specific care needs and the support to be provided by staff.

Is the service responsive?

Our observations during the inspection showed that visiting times were flexible.

We found that there were appropriate arrangements in place pertaining to complaints management.

Is the service well-led?

The provider was not fully able to demonstrate that there were suitable systems in place to assess and monitor the quality of the service provided. None of provider's systems had highlighted that there were gaps in relation to consent to care and treatment and staffing levels. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance.

We saw that people's care needs were assessed and planned for with any risks associated with their care being minimised as far as possible.

People told us that they could do what they wished and were given choices in their daily lives.

People had the equipment they needed to support their care needs and keep them safe. Equipment was monitored and maintained.

Staff said that they were well supported and had opportunities for training. We saw that staff were trained in essential areas such as moving and handling. Staff had also received training in dementia care to help ensure good and consistent practice.

People spoken with thought that the staff knew what they were doing and were generally available to them when they needed assistance. We did find that staffing levels needed to be reviewed to ensure that people always received a timely response when they needed assistance, particularly during the night.

We found that people felt able to raise complaints or concerns about any aspect of the service. People's complaints were looked into and resolved where possible.