Eleanor Palmer Trust Home

Eleanor Palmer Trust is a residential care home providing personal and nursing care to up to 33 people. The service provides support to older people some of whom are living with dementia. At the time of our inspection there were 33 people using the service.

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

There had been management changes since the last inspection, which affected the overall service management. The provider had been working to improve the quality and safety of the service. They continued to work with the local authority quality assurance team.

The new registered manager was in the process of getting to know the service, introducing and establishing new systems and processes, and a clearer structure with more effective monitoring and accountability. However, these changes had yet to be fully established and embedded.

We found medicines were not always managed safely, which placed people at increased risk of harm. Systems and processes were not always in place to check people had received their medication safely. Medicines audits were not robust enough to check people were receiving their medicines as prescribed or that the service was managing medicines in line with national guidance.

People were supported by staff who had been checked to ensure they were safe to work at the service and there were sufficient staffing levels in place. People told us they did not have to wait long for staff support when using their call bells. Staff had received a range of training and development. Supervision to support and monitor practice was undertaken.

The staff team followed procedures and practices to control the spread of infection and keep the service clean. There was an emergency plan in place to respond to unexpected events. The premises were well maintained, and some areas were being refurbished to meet the needs of people living at the service.

People were safe living at the service and relatives felt their family members were kept safe. Staff understood their responsibilities to raise concerns and report incidents or allegations of abuse. They felt confident issues would be addressed appropriately.

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.

People were able to access healthcare professionals such as their GP. The service also worked with other health and social care professionals to provide effective care for people. People were supported to access appropriate food and fluids and meals were described as being good.

People told us they were happy with the care they received, and staff were kind and helpful. People's choices were considered when providing care and their views were considered. Staff had a good understanding of people as individuals and people were treated with dignity and respect.

Relatives felt the management of the service was improving and that they could approach the registered manager and staff with any concerns. Staff felt the management was open with them and communicated what was happening at the service and with the people living there.

Improvements to audits and management oversight of the service were being put in place by the registered manager and these needed more time to have a positive impact on the service.

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 requires improvement (published on 18 November 2021). 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 some improvements had been made but the provider remained in breach of one regulation, related to the management of medicines. We have also made a recommendation in relation to sustaining the overall improved standards.

At our last inspection we made a recommendation about making adaptations to the home, person centred care planning and managing complaints. At this inspection we found the provider had acted on the recommendations and they had made improvements.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection and addressed the issues set out in the Warning Notice.

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.

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

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.

Eleanor Palmer Trust Home (also known as Cantelowes House) is a residential care home providing nursing and personal care for up to 33 people, some of whom are living with dementia. At the time of the inspection there were 33 people living in the home. The home is purpose built consisting of two floors, with a communal dining room and lounge on the ground floor.

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

People and relatives told us they felt safe with the care and support they or their relative received. People's basic care and support needs were met, and people and relatives spoke positively of the service. However, we found significant concerns with the management of medicines, safeguarding, deprivation of liberty safeguards, staff training, support and recruitment which placed people at increased risk of harm.

Management oversight of the service was ineffective and did not identify the issues we found during the inspection. Managers were not completing audits in the areas where we found concerns and there was a lack of formal engagement with people, staff and relatives.

Concerns about people using the service were not always responded to appropriately. We found instances where CQC had not been notified or where notifications had been submitted with significant delays.

People and relatives told us staff were suitably skilled and knowledgeable, however some staff told us they did not feel supported and that staff morale was low. We found that not all staff had completed training, staff were not being regularly supervised and individual staff performance had not been reviewed.

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. However, we found that appropriate authorisations were not in place to deprive people of their liberty.

People had access to a balanced and healthy diet and were satisfied with the food on offer. People were supported by staff that knew them well and people told us they were able to make everyday choices and received support when they wanted it. People had access to a range of activities, however some people and staff told us more activities should be offered.

We recommended the provider makes further adaptations to the home to ensure it is accessible for people living with dementia.

We recommended the provider reviews peoples care records to ensure they contain sufficient details of people’s preferences and choices.

We recommended the provider reviews its processes and procedures for managing complaints.

Most people and relatives told us they felt very satisfied with the support they or their relative received from the service.

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 December 2018). At this inspection the rating has deteriorated to requires improvement.

Why we inspected

We received concerns in relation to management of medicines, nutrition and hydration, staff training and the management of people’s risks. As a result, we undertook a focused inspection to review the key questions of safe, effective, responsive and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key question. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good 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, responsive and well-led sections of this full report.

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 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.

We found several breaches of regulation and issued the provider with a warning notice in relation to good governance.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve. We will work with the 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.

Eleanor Palmer Trust Home, also known as Cantelowes House, is a ‘care home’. The accommodation is purpose-built with passenger lift access to the first floor. People living in this care home receive accommodation along with nursing and 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.

The service had a registered manager, which 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 service is registered to provide accommodation for up to 33 people. There were 28 people using the service at the start of this inspection. The service specialises in the care of adults including those with dementia. It is operated by The Eleanor Palmer Trust, a voluntary organisation.

The service’s registration was altered to allow nursing care in the Spring of 2018. However, the registered manager informed us that nursing care had not been provided in practice so far, and would not start until they were confident that aspect of the service could be successfully maintained.

At our last inspection of this service in September 2017, we found one breach of legal requirements. These was in respect of duty of candour following serious injuries to people using the service. The provider completed an action plan to show what they would do and by when, to address this breach and so improve the rating of the service to at least ‘Good.’ At this inspection, we found the necessary improvements had been made to addresses the previous regulatory breach. This has helped to improve the service’s overall rating to ‘Good.’

However, the rating for ‘Is it Safe?’ remains ‘Requires Improvement.’ This is because we identified some concerns about upholding infection control and health and safety standards. The lounge carpet was significantly stained, and the kitchenette near the lounge and some equipment used by people had signs of wear and tear. This compromised infection control standards. We also found one person being hoisted in a sling that was not the most appropriate for their needs. The service had not undertaken effective audits in these areas to identify and address these shortfalls. The registered manager sent us information during and after the inspection visits to show these matters were being addressed.

We have recommended the provider review and implement best practice guidance on infection control in care and nursing homes.

People using the service spoke positively about it, describing it as “wonderful” and “the best care home in the world” for example. Everyone said they would recommend it to friends and family. People’s relatives and representatives provided similarly positive feedback.

There was a comfortable and engaging atmosphere at the service. Staff spoke in a positive manner about different people using the service, and had time for them. People were treated with kindness, respect and compassion, and were given emotional support when needed, sometimes from other people using the service.

The service provided people with a range of mental and physical stimulation. People were supported to develop and maintain relationships that mattered to them, and there were no restrictions on visitors.

People were supported have access to healthcare services and receive ongoing healthcare and nutritional support. This included through the proper and safe use of medicines.

The service enabled people to receive personalised care that was responsive to their needs. This was based on comprehensive initial assessments of people’s needs and preferences, and regular reviews to ensure changes were taken on board.

The service provided sufficient numbers of suitable staff to support people to stay safe and meet their needs. Staff were trained and supervised in support of this.

The adaptation, design and decoration of premises generally supported people's individual needs to be met. Some improvements were being planned for.

The service was generally working within the principles of the Mental Capacity Act 2005 in terms of consent to care, but records of this were inconsistently kept.

The service had a positive and inclusive culture with a strong team ethic and effective leadership that achieved good outcomes for people. It worked in partnership with other agencies to support care provision and development.

The provider’s governance framework and engagement with stakeholders helped to ensure sustainability and the development of the service.

Eleanor Palmer Trust Home, also known as ‘Cantelowes House’, is a care home that is registered to provide accommodation and personal care for up to 33 people and specialises in dementia care. The home is run by The Eleanor Palmer Trust, a voluntary organisation. There were 20 people using the service at the time of this inspection. This was because, following our December 2016 inspection, the provider had made a decision to temporarily stop admissions into the service until care delivery concerns were addressed.

The service had a registered manager, 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.

We found significant improvements in people’s care and service quality at this inspection. This matched the overall feedback we received from people and their relatives, most of whom praised the capability and approach of staff and the effectiveness of the management team.

Risks to people were appropriately managed so as to keep them safe. This included for pressure care management, unexplained bruising, and for falls. People were supported to move around safely.

Everyone was supported to gain health professional input when needed. The service paid good attention to people’s health, nutrition and hydration needs. People were supported to have regular baths and showers. People’s medicines were properly managed so that they received them safely and as prescribed.

Feedback and our observations showed people were treated in a kind, friendly and respectful manner. Attention was paid to supporting people with their appearance. Choice and independence was promoted.

There were enough suitable staff to keep people safe and meet their individual needs. Whilst there was some reliance on staff from a specific care agency, many of these staff had worked at the service for a while. Staff at the service knew people’s individual needs and preferences, and treated them well.

The service had worked hard at setting up extensive care plans that encompassed a range of individualised needs and preferences and guided staff on providing responsive care. Feedback and our observations showed people received individualised care.

Staff reported an open and empowering culture, good teamwork, and an approachable management team. There were improved standards of record-keeping, which helped document people’s care and helped communicate key information to incoming staff. There were also audits of care quality and risk management, to help ensure good quality care was being delivered.

However, the service required improvement in a few areas. There was an inconsistent approach to documenting health and safety checks and ensuring actions took place as a result of a professional fire safety risk assessment.

Duty of Candour requirements had not been formalised and documented in respect of two incidents of people being admitted to hospital with injuries. Whilst there was no suggestion these injuries were avoidable, this did not demonstrate an open culture of learning from incidents so as to minimise the risk of reoccurrence.

The service was almost working within the principles of the Mental Capacity Act 2005 (MCA), but capacity assessments of people’s ability to consent to specific care decisions were not consistently following these principles. This put people with greater needs at risk of being subject to care practices without appropriate consent.

Staff supervision processes were not yet embedded as an ongoing practice, to help ensure staff provided effective care. However, staff were suitably trained for their care roles.

This comprehensive inspection identified one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in respect of Duty of Candour processes. You can see what action we told the provider to take at the back of the full version of the report.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Eleanor Palmer Trust Home, also known as ‘Cantelowes House,’ is a care home that is registered to provide accommodation and personal care for up to 33 people and specialises in dementia care. The home is run by The Eleanor Palmer Trust, a voluntary organisation. There were 20 people using the service at the time of this inspection. This was because, following our December 2016 inspection, the provider had made a decision to temporarily stop admissions into the service until care delivery concerns were addressed.

After the last inspection, the provider paid a Fixed Penalty Notice we served on them in respect of failing, without reasonable excuse, to comply with a condition of their registration about having a registered manager at the service since May 2016. 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. A new manager had been appointed in February 2017 and was registered in that role shortly after this inspection.

At this inspection, we found that a number of the concerns raised with us were valid. There were cases of unexplained bruising and injuries which the manager told us they were not aware of. Referrals were made to the local authority’s safeguarding team as a result.

We found the manager had not reviewed and signed off some incident forms, nor were they aware of some other safety matters relating to people using the service that had not been recorded as incidents. Risks relating to these matters had not therefore been properly assessed and addressed.

We found people were not being supported to have baths or showers regularly. This put people at unnecessary risk of developing health concerns. One person’s hearing aid was not working properly but staff had not identified this. Another person’s repositioning records, in support of helping pressure ulcers to heal, were not consistently written at night and were not occurring during the day. People’s care was not therefore sufficiently meeting their needs or reflecting their preferences.

The service was liaising well with community healthcare professionals for some matters, for example, where concerning weight loss had been identified or if someone was showing symptoms of an infection. However, monitoring systems were not working where people were experiencing constipation, as contact with healthcare professionals was not occurring in a timely manner when needed. The process took four extra days for one person, who ultimately needed an enema which may have been avoidable if the service had identified and addressed the welfare risk faster. People were not experiencing safe care and treatment as a result of this.

We found that medicines were not safely managed on a consistent basis. One person missed four days of a prescribed twice-daily medicine due to insufficient stock being received and the service not making arrangements to address this promptly. There were occasional unexplained gaps in the records of medicines administration despite systems being set up to identify and prevent this. Daily stock check records were not consistently accurate.

There was some ineffective staff communication which did not support people to receive safe care and treatment. Some important information relating to individuals using the service was not recorded on staff handover sheets to show that incoming staff had been informed. During our visit, the shift-leader was not aware that a specific medicine for someone was due to run out but that a reorder had been made and needed following up on.

Records relating to people’s care and treatment were not consistently completed. This included gaps in the write-ups of people’s daily care, in application of topical creams for skin care, and in staff handover sheets not always being filled out. Weekly manager reports to the provider did not accurately reflect all incidents of safety risks occurring at the service.

A regularly-arranged visit from a representative of the local authority a few days before this inspection identified that relevant people’s fluid charts for that day had not been filled out by lunchtime. At our unannounced visit, food and fluid charts were being filled out in a timely manner. Staff paid a lot of attention to ensuring people had enough to drink, and people were provided with good support at lunch.

There were enough staff working at the service. Experienced staff knew people well, but there was some reliance on agency staff. People and their visitors generally provided positive feedback about staff at the service. However, there was some feedback about the impact of staff turnover providing a less responsive service.

We saw safe moving and handling of people including during hoisting. Staff provided people with choices about care and acted on their responses. Whilst there were no activities provided in the daytime, during the early evening, staff sung a variety of songs that many people joined in with.

There were overall three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 arising at this inspection. You can see what action we told the provider to take at the back of the full version of the report. Full information about CQC’s regulatory response to any 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 returned to ‘Special Measures’. It was in special measures between December 2016 and June 2017 inspections.

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 undertook a focused inspection on 7 March 2017 to check that the Warning Notices had been addressed. We found this had not occurred in respect of safe care and treatment, and good governance. Additionally, we identified a further breach of legislation regarding staffing levels. The service remained in ‘Special Measures’ and we undertook further enforcement action. The provider sent us an action plan in respect of the three breaches.

We undertook this focused inspection, of 1 June 2017, to check that the provider had followed their plan and to confirm that they now met the legal requirements relating to the three breaches. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Eleanor Palmer Trust Home on our website at www.cqc.org.uk .

Eleanor Palmer Trust Home, also known as ‘Cantelowes House,’ is a care home that is registered to provide accommodation and personal care for up to 33 people and specialises in dementia care. The home is run by The Eleanor Palmer Trust, a voluntary organisation. There were 21 people using the service at the time of this inspection. This was because, following our December 2016 inspection, the provider had made a decision to temporarily stop admissions into the service until care delivery concerns were addressed.

There had been no registered manager in post since May 2016. 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. A new manager had been appointed in February 2017 and had applied for registration as manager of the service.

At this inspection, we found that breaches of legislation identified from our last inspection had been addressed. There were now enough staff deployed to work at the service. This helped keep people safe and enabled their needs to be met. There was better interaction with people, and greater activity provision. People were hoisted safely. There was now documented guidance on when to offer people their as-needed medicines, in support of these being provided when needed. The lounge was also kept at an appropriate temperature.

People were receiving good support with their nutrition and hydration needs. We generally found that healthcare professional advice was being acted on, to support the health and welfare of those the advice related to. Staff were being supported to uphold appropriate skills to help ensure effective care.

There were improved governance systems in place including new auditing processes and refinements of other processes, which helped identify and address service risks. The effectiveness of the management of the service was evident through improvements to the overall care provided to people.

There were some areas requiring further improvement. Records of the care provided to people were more accurate and complete. However, there was insufficient consistency of records in support of effective care evaluation. Systems of individual risk assessing and care planning were improved, but the process had not yet been completed for everyone using the service. We also found that a sensor mat was not in one person’s room to help prevent night-time falls, despite this being part of their care plan.

Due the feedback from some staff and checks of records, we have recommended that the provider review its whistle-blowing policy and the effectiveness of the procedure against national guidelines, to ensure it supports a positive working culture at the service.

Nonetheless, people using the service and their relatives all said they would recommend the service. As one relative put it, ““No place is ever perfect but this one has a good service and staff are really friendly.”

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures. However, the service remains in breach of some regulations arising from the last comprehensive inspection which we did not check on at this visit as we were checking on breaches relating to enforcement action we took. We will check on remaining breaches at the next comprehensive inspection.

We undertook this focused inspection of 7 March 2017 to check that the provider had followed their plan and to confirm that they now met the legal requirements relating to the warning notices. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Eleanor Palmer Trust Home on our website at www.cqc.org.uk .

Eleanor Palmer Trust Home, also known as ‘Cantelowes House,’ is a care home that is registered to provide accommodation and personal care for up to 33 people and specialises in dementia care. The home is run by The Eleanor Palmer Trust, a voluntary organisation. There were 22 people using the service at the time of this inspection. This was because, following our last inspection, the provider had made a decision to temporarily stop admissions into the service until care delivery concerns were addressed.

There had been no registered manager in post since May 2016. 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 manager at our last inspection, who had been in post from April 2016, left the service at the start of February 2017. A new manager had been appointed shortly afterwards and was in post for a month at the time of this inspection.

At this inspection, we found that the provider had followed their plan to address our previous concerns relating to meeting nutritional and hydration needs. However, they remained in breach of legal requirements relating to safe care and treatment, and to good governance, despite some evidence of addressing matters relating to our Warning Notices. We also found an additional breach of legal requirements relating to staffing levels.

Individual risk assessments were not kept consistently up-to-date so as to help keep people safe. This included for one person who was being hoisted, where their moving and handling risk assessment stated they were independent. Despite two recent falls, their falls risk assessment had not been reviewed and updated.

Another person had recently left the premises unsupervised, contrary to their care plan. However, this incident had not been reviewed, to minimise the risk of reoccurrence.

One person was sometimes aggressive to staff. However, there was no care plan in place about this, to help keep them and staff safe. Incidents were not consistently recorded and were not kept under review.

One person experienced pain whilst being hoisted. There was no care plan to manage this, or guidance for their as-needed pain management medicine. There were no guidelines in place for anyone’s as-needed medicines.

One person had a care plan in place to help manage their risk of falling, as they experienced frequent falls. However, their care records and our observations did not show that the plan was being followed.

There were not enough staff deployed to work at the service, as staffing levels had been cut without checking that people’s needs could still be safely met. Consequently, at lunch we saw some people waiting in the dining room for over half an hour to receive their first course, and dependent people did not consistently get the staff support they needed.

The lounge was very warm during the inspection. It was one degree Celsius higher than the advised maximum temperature in the Public Health Document “Heatwave plan for England – advice for care home manager and staff.” We noted many people slept there, and there was insufficient support and stimulation for people with greater dependency needs.

Records of the care provided to people were still not consistently accurate and complete. Food and fluid charts for four people were not accurately filled in, and on the day of our visit, three had been filled in in advance of the food and drink being provided. Inaccurate and incomplete records undermined appropriate care practices and meant information could not always be easily accessed when needed.

However, some improvements had been made. People were now receiving their day-to-day medicines as prescribed. The needs of some people at high risk of malnutrition and dehydration were being better met. We generally found that healthcare professional advice was now being acted on, to support the health and welfare of the involved people the advice related to. There was better morale and team work evident at this inspection.

Most people using the service that we spoke with, and all relatives, said they would recommend the service. One relative explained this was “because the staff are so lovely and kind.”

Nonetheless, the breaches identified in this report indicate ongoing ineffective governance of the service. There were insufficient improvements to the health, safety and welfare of people using the service despite us serving three Warning Notices on the provider soon after our last inspection. The provider remained in breach of two regulations relating to those Warning Notices, in respect of regulation 12 (safe care and treatment) and regulation 17 (good governance). There was also a further breach of regulation 18 in relation to staffing levels. The service remains in ‘Special Measures.’

You can see what action we told the provider to take at the back of the full version of the report. However, full information about our regulatory response to the concerns found during this inspection will be added to this report after any representations and appeals have been concluded.

The inspection was prompted in part by four people raising recent concerns with us, and notifications of two incidents where people using the service fell, following which one person died and the other sustained a serious injury. These incidents may be subject to criminal investigations and as a result this inspection did not examine the circumstances of the incidents. However, the information shared with CQC about the incidents indicated potential concerns about the management of risk of falls. This inspection examined those risks.

At the last inspection on 23 February 2016, we asked the provider to take action to make improvements, to ensure staff received sufficiently regular supervision and appraisal, and training in a format that supported them to meet people's needs effectively. The provider subsequently wrote to us to say what they would do in relation to this breach of legal requirements.

There had been no registered manager in post since May 2016. 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. A new manager had been appointed shortly after our last inspection, whom we met during this inspection. They had not started the process of applying to be the registered manager.

Most people using the service provided good feedback about it. They felt the service was safe, that staff were caring, and that there was good food and drink. There were mixed views on whether there were enough staff.

However, we found some significant concerns about how the service was operated that particularly undermined people’s ongoing safety and welfare.

We found that prescribed medicines were not safely managed. At both visits medicines had not been given to people without reasonable explanation. This included medicines left in the monitored dosage packaging, for which there was no improvement by the time of our second visit despite us informing the manager of our concerns at our first visit.

One person was having a phased change of anti-psychotic medicines following psychiatrist advice. At our first visit, we found that the phased approach had not occurred as planned, and that the new medicine had run out the day beforehand with no plans to acquire more of the medicine. Despite the manager being informed of this, at our second visit, the medicine remained out of stock with no reasonable explanation, meaning the person had gone over two weeks without the prescribed medicine. Care and treatment was not provided to this person in a safe way.

Where people were experiencing falls, there were not often documented reviews of their falls risk assessments and adjustments to their care plans so as to minimise the risk of reoccurrence. One person had a fall during our first visit. At our second visit, we found there was no updated falls risk assessment in place for them since February 2016, despite this fall and another three months earlier that resulted in a check at a hospital due to a swollen eye.

The service did not have consistent systems for keeping people’s individual risk assessments and care plans up-to-date. One person was assessed under their old care plan in February 2016 as being at risk of absconding. This was not transferred over to their new care plan. A recent incident of them being found outside the building had not resulted in a documented review of managing this risk and updating their care plan.

One person moved into the service a month before our first visit. A care plan was not started for them until twelve days later, and no risk assessments were in place for them at the time of our second visit except for an undated community falls referral form. This was despite them having two falls during their first week in the service, one of which resulted in paramedics being called due to them hitting their head. Their nutritional care plan also failed to document their diabetes, and we saw that they were not on the list kept in the kitchen of people with diabetes.

One person had a bruise near one eye at our second visit. Their care plan had not been reviewed to reflect this bruise, despite the bruise being a week old. Most care records since then did not document the bruise. The person also had no falls risk assessment on file, despite being found fallen a few months previously.

Community professionals provided mixed feedback about how well the service worked in co-operation with them. We found that records of healthcare professional input were not easily accessible and in some cases were not available. Additionally, we found cases where healthcare professional advice from a dietitian, an optician and a GP had not been acted on, which did not ensure the health, safety and welfare of the people the advice related to.

Whilst staff generally worked together to aim to meet people’s needs and requests, there were occasions when we saw people with greater support needs being treated carelessly or without due respect. There were also occasions when people were not given appropriate choice around food and drink.

Records of the care provided to people, and of the management of the service, were not consistently up-to-date, complete and accessible. This undermined appropriate care practices and meant information could not always be easily accessed. For example, whilst there was feedback about recent staffing shortages from staff and people using the service, there was no accurate record of which staff worked when.

There was ongoing failure to effectively meet the needs of some people at high risk of malnutrition and dehydration. There were a number of gaps in the food and fluid charts of such people at our first visit. Prompt action was taken to improve on these matters by our second visit, at which time the manager had also produced a weight-monitoring chart for people using the service. This confirmed our findings from the first visit, that there had been significant gaps in monitoring the weight of some people at risk of malnutrition, although it was encouraging that oversight of that concern was now being established.

Most staff we spoke with during the inspection process reported poor morale. Comments included about the service being poorly run, of not being listened to, and of having no effective outlet by which to raise concerns. We found that the service was not appropriately supporting staff in their roles. Planned individual supervision meetings and staff meetings were infrequent, and records identified that a number of staff had not received recent training on certain key aspects of the work, including for safeguarding people from abuse, fire safety, dementia care, and nutrition.

We also found significant concerns with how well-led the service was. There were ineffective governance systems in place, and so we identified shortfalls that the management team and the provider had not recognised or addressed. This included significant medicines safety concerns, despite an internal audit on the first day of our visiting that identified no concerns. Visits from representatives of the provider were also not identifying significant concerns such as people going into hospital following falls.

The provider had not kept us promptly notified when significant events occurred at the service, contrary to legislation. This prevented us from monitoring the service effectively.

There were overall eleven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and two breaches of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of the report.

As a result of the concerns we identified, principally that the provider was not meeting the needs of people using the service who may therefore have been at risk of harm, we sent the provider a letter of intent on 16 December 2016 outlining our most serious concerns. The letter informed the provider of enforcement action we were considering, and requested an urgent action plan setting out how the provider intended to address these concerns. An action plan was promptly sent that planned to address the most serious concerns. We therefore reviewed our enforcement options, and served three enforcement Warning Notices on Eleanor Palmer Trust, to help ensure that prompt action is taken to address the most serious concerns we identified during this inspection.

The manager informed us on 22 December 2016 that the provider had made a decision to temporarily stop admissions into the service until care delivery concerns were addressed.

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

The home did not have a registered manager as the previous registered manager was no longer working at the home. 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. There was an acting manager in place who advised that recruitment was being undertaken to appoint a new manager to register with the Commission.

At the previous inspection in July 2014, the home was not found to be sufficiently clean. We found that the home was clean and there was a deep cleaning programme in place during the current visit. The home was also in a good state of repair, and equipment was maintained appropriately.

There had been an increase in staffing numbers since the previous inspection. Safe systems were in place for recruiting staff. However staff had not receive sufficiently regular supervision meetings and training was not always provided in a format that they found useful, within the last year. A variety of activities were available to people, however no activities were available to people in the afternoons.

People told us that their care needs were met, and their views were taken into account. They were provided with their medicines safely. People who were unable to consent to care had best interest decisions recorded for them, and deprivation of liberty safeguards were in place for people who required this.

Detailed care records were in place regarding people’s care however this was not always easy to access due to the formats for recording. Accident and incident records did not include a section for learning from what had happened, and improvements were needed in the recording of bruising and skin marks for people living at the home.

Staff showed a good knowledge of people’s life histories and preferences regarding their care and support needs. They were clear about the procedures for reporting abuse and felt that management listened to their views.

People were provided with a choice of food at meal times, and were supported to eat when this was needed. They spoke positively about the food provision in the home. People’s health needs were met, and they were supported to consult with health and social care professionals as needed without delay. They had the opportunity to be involved in decisions about their care and how they spent their time at the home. They and their relatives attended meetings or spoke directly to a manager to raise any issues of concern.

The provider had systems for monitoring the quality of the service and engaged with people and their relatives to address any concerns. When people made complaints they were addressed appropriately.

At this inspection there was one breach of regulations, in relation to staff supervision and training. 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, speaking with people using the service, the staff supporting them and from looking at records. If you want to see the evidence supporting our summary please read the full report.

This inspection was carried out on a Sunday. There were thirty-one people living at the home at the time of the inspection. We spoke with eight people living at the home and six people visiting people at the home.

Is the service safe?

People told us that they felt safe within the home, with appropriate staff support. They told us 'I'm alright,' and 'Everything's alright.' It was a hot day on the day of our visit, and we saw staff offering people drinks on a regular basis.

At the previous inspection a compliance action was made regarding the home's recruitment procedures. During the current visit we found that recruitment systems were sufficiently rigorous to ensure that new staff were of good character for the protection of people living at the home.

Is the service effective?

People living at the home and their relatives told us that staff were competent at meeting their individual needs effectively. Comments included 'Staff are always around,' and 'They look after me at night.' Staff said that they received appropriate support to enable them to deliver care to people to an appropriate standard. People were supported to undertake some activities within the home and join in social groups outside of the home. They were satisfied with the food provided to them.

However during our visit we found that some areas of the home were not sufficiently clean. These included the carpets in some bedrooms and communal areas and the dining room chairs. We received mixed comments from people about the home's cleanliness, with some praising the standards, whilst others were concerned about particular issues. There were no cleaning schedules or checklists available, and no infection control audits had been undertaken. We were told that there were some domestic staff shortages due to sickness and annual leave. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to providing effective infection control within the home.

Is the service caring?

People were very satisfied with the way they were cared for at the home. They told us 'The staff are lovely, I'm generally very happy here,' 'I find it very nice,' 'Everything's done for you,' 'If you are worried about something, talk to someone and they put it right,' and 'They can't do enough for me.'

Is the service responsive?

At the previous inspection a compliance action was made regarding insufficiently rigorous assessment of people's needs, and planning and delivery of care to meet them. During the current visit we found that there were improvements in recording of repositioning charts for people when required to protect them from pressure sores. There were also improvements in recording people's weights on a regular basis, and updating their nutritional assessments. Records of people at risk of falls now included updates following falls to prompt further actions to address risks.

Is the service well-led?

Staff told us they were clear about their roles and responsibilities. Staff we spoke with showed that they understood the needs of individual people they cared for. People living at the home had confidence in the home's management. They told us 'No complaints,' 'The manager is very good,' and 'If you have a complaint its dealt with in two to three days.'

People told us there were different activities provided every day. Comments included, 'you can't get bored here.' We found that people were treated with respect and dignity, and were supported in promoting their independence.

There was positive feedback about how the service worked with healthcare professionals. We found that the provider worked in co-operation with others to help meet people's individual needs.

People informed us that staff and the manager were approachable. Comments included, 'they always listen.' We found there were systems to assess and monitor quality at the service, and to address people's comments and complaints.

However, we found that systems of planning and delivering care in respect of weight and nutrition, falls, and pressure care management, were not always meeting people's individual needs and ensuring their welfare and safety.

We also found that recruitment procedures did not establish the good character of applicants before they began employment. Some newer staff were employed before any aspect of a Disclosure and Barring Service check had been acquired. This put people using the service at unnecessary risk.

People told us that their care needs had been attended to and they were well cared for. Assessments, including risk assessments had been carried out. Care plans had been prepared and these were reviewed regularly. The home had a varied programme of social and therapeutic activities. We noted that there was a high incidence of falls in the home. However, action was being taken to reduce falls.

There were suitable arrangements in place to manage medicines. The medication records examined indicated that people had been given their medication as prescribed.

People spoke well of staff and indicated that staff were capable. Staff had been provided with essential training and support. We noted that there were some shortcomings in the way a recent safeguarding incident was handled. However, action had been taken to ensure that future safeguarding incidents would be handled more effectively.