Elmstead House

We last inspected the service on 6 and 17 July 2017 and found the service to be in breach of Regulations 17 and 18 of the Health and Social Care Act 2008. Issues identified included staff not receiving regular supervision to support them in their role and the lack of regular monitoring and auditing to ensure that health care checks and monitoring were appropriately completed.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the ratings of the key questions of effective and well-led to at least good.

Elmstead House is a ‘care home’. 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.

Elmstead House accommodates up to 50 people across two separate units, each of which have separate adapted facilities. One unit supports elderly people some of whom were living with dementia. The other unit is a functional mental health unit which supports people with recovering and enduring mental health problems. At the time of this inspection there was 37 people living at Elmstead House.

A manager was in post at the time of this inspection and had submitted an application to the CQC to become the 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.

At this inspection we found that the service had made improvements to address previous issues that we had found. However, further improvements were required in relation to staff receiving regular, formal supervisions and annual appraisals.

Staff that we spoke with confirmed that they felt supported in their role and received regular supervisions and annual appraisals. However, records seen did not always confirm this. The newly appointed manager was aware of this and had plans in place to ensure all staff received regular, formal supervisions and an annual appraisal.

People and their relatives told us that they felt safe living at Elmstead House. All staff demonstrated a good understanding of safeguarding people from abuse and the actions they would take to report their concerns.

People’s care plans contained comprehensive information about identified risks associated with their health and social care needs and clear guidance for staff on how to support people to be safe and free from harm.

Staffing levels were determined based on individual people’s levels of need. We saw that there were sufficient number of staff available around the home.

Recruitment processes ensured that only those staff assessed as safe to work with vulnerable adults were recruited.

People received their medicines safely, on time and as prescribed. Medicine policies and processes in place supported this.

Accidents and incidents were recorded, reviewed and analysed to ensure that where things had gone wrong improvements and further learning were considered and implemented.

Staff received a comprehensive induction when they first started work at the home with regular on-going training which enabled them to deliver effective care and support.

People’s needs and preferences were assessed prior to their admission to Elmstead House so that the home could confirm that these could be effectively met.

People had access to a variety of snacks, drinks and regular meals which helped them to maintain a healthy and balanced diet. Where people had specialist diets and support needs in relation to their dietary intake this was appropriately catered for.

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

People had access to a variety of health care professionals to ensure they were able to maintain a healthy lifestyle. The service worked effectively within as well as with other healthcare professionals so that people had access to specialist and relevant services which addressed and met their identified health and care needs.

We observed positive and caring interactions between people and staff. Staff knew the people they supported well and treated them with dignity and respect at all times.

People were supported to be involved in all aspects of the delivery of their care and support where possible. Relatives also confirmed that the home always involved them in every aspect of their relative’s care.

Care plans were detailed and person centred which gave specific information and guidance to staff on how to meet people’s identified needs and wishes.

People and relatives knew who to speak with if they had any concerns or complaints to raise and were confident that their concerns would be dealt with appropriately.

Management oversight processes in place ensured that the manager and provider monitored the quality of care people received. Where issues were noted, an action plan was compiled with details of the actions taken and lessons learnt.

Elmstead House is a nursing home that is registered to provide accommodation with nursing and personal care for up to 50 people. The service specialises in dementia, diagnostic and/or screening services, learning disabilities, mental health conditions, physical disabilities, and caring for adults over 65 years old. The home was divided into two units, one for people who are living with dementia and are physically frail, and the other for people with a mental health diagnosis. At the time of the inspection there were 36 people living in the home with 21 people in the dementia unit and 15 in the mental health unit.

We undertook a focussed inspection in November 2016 when we looked at three domains Safe, Effective and Well-Led. We found that the service required improvement in the Safe domain as staff practice was poor with regard to infection control that resulted in a breach of the regulations. We had concerns about the security of the building as such we made a recommendation the provider took advice from an expert in security management. During this inspection, we found that the concerns with regard to infection control and security of the building had been addressed.

At the November 2016 focused inspection we found the service required improvement in the Effective domain as there were significant gaps in health recordings as such the service did not maintain robust monitoring of people's wellbeing which was a breach of the regulations. In addition, although people were offered a choice of meals there was not always access to snacks and drinks during the day.

During this inspection, we found that there was a new and varied menu and we saw snacks and drinks being offered throughout the day. Most people’s health recordings such as food consumption charts, fluid charts, welfare checks, and repositioning charts were undertaken without omission. However, one person’s did not have accurate and complete recordings. Their repositioning charts contained gaps and their welfare chart contained gaps. Food charts were completed for all people but recordings did not contain information to show if the food given had been fortified as the dietician directed. Fluids charts showed clearly if people had received their identified intake for the day and the day recordings were without gaps. However, there was little or no recording of drinks offered or consumed at night. As such whilst we acknowledged improvements had been made there was still work to be undertaken to embed the recording system. As such, we found a repeated breach of the regulations.

In addition, during this inspection we found staff supervision sessions was not taking place for many staff. As such, we found a breach of regulations.

At our previous inspection we found Well-led inadequate as there was not a registered manager in post since January 2016 and staff morale was low. Although the service had undertaken checks and quality assurance audits these had not been effective in identifying and addressing the recording, infection control and security concerns we found during our inspection.

During this inspection, we found there was a manager in post who had applied to become a registered manager with the CQC. They became the registered manager shortly after our visit to the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found that the staff morale had improved for some staff but not all. The provider had taken action to meet with staff. However, lack of staff supervision meant staff were not receiving either group or individual sessions to raise their concerns and have their performance feedback.

People and their relatives told us staff were kind, respectful, and caring. People’s relatives were involved in their care planning.

We found there were robust recruitment practices and good training for staff. There were adequate staff to meet the needs of the people using the service.

Safeguarding adult concerns were addressed appropriately. Risks to people were assessed and measures put in place to minimise risk. Medicines were administered and stored in a safe manner.

Staff worked to the Mental Capacity Act 2005 (MCA) and appropriate Deprivation of Liberty (DoLS) applications had been made.

People were supported to access appropriate health care in a timely manner. People had their end of life wishes recorded.

The staff provided both group and individual activities to engage people.

People and relatives spoke favourably about the manager and found them approachable. There were good lines of communication in the service.

The provider had a complaints policy and procedure. We saw complaints had been addressed appropriately.

We found two breaches of the regulations.

You can see what action we told the provider to take at the back of the full version of the report.

Elmstead House is a nursing home that is registered to provide accommodation with nursing and personal care for up to 50 people. The service specialises in dementia, diagnostic and/or screening services, learning disabilities, mental health conditions, physical disabilities, and caring for adults over 65 years old. The home was divided into two units, one for people who are living with dementia and are physically frail, and the other for people with a mental health diagnosis. At the time of the inspection there were 44 people living in the home with 28 people in the dementia unit and 16 in the mental health unit.

Prior to this inspection we had carried out an unannounced comprehensive inspection of this service on 16 June 2015 at which two breaches of legal requirements were found. This was because people were not fully protected against the risks associated with medicines. There were also some gaps in records for people who were unable to consent to care and required best interest decisions to be made on their behalf, so it was not always clear if all relevant parties had been consulted in line with the Mental Capacity Act 2005. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We found the service was meeting these legal requirements when we undertook a focused inspection on the 10 December 2015.

The service had not had a registered manager since January 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. There was a recently appointed manager who told us they intended to apply for registration.

During our inspection we found three breaches of the regulations in infection control, nutrition and hydration and good governance.

Although staff had received infection control training we observed poor infection control practice in particular the disposal of protective equipment such as gloves and contaminated waste.

We found people were offered a good choice of meals however they did not have access to snacks throughout the day. In addition drinks were not available to people at all times. We found some fluid charts contained significant gaps in recording. This meant that people were not being effectively monitored to ensure they remained well hydrated.

Daily recordings such as re-positioning charts to manage pressure ulcers care contained significant gaps. This meant that people were not being monitored effectively to ensure their medical conditions were well managed. We found that the nursing staff were well informed about people’s health requirements. People were supported to access health care professionals. Nurses demonstrated they understood what medicines they administered were used for and we found medicines were stored safely. Administration was completed appropriately in the majority of instances.

Although there were governance systems in place to assure the quality of the service given we found that these had not been effective in monitoring and addressing the issues we found during our inspection. In addition staff morale was low and the provider had not ensured staff felt valued and listened to. Staff told us they were too short staffed at times to meet the needs of people living at the service. The provider demonstrated to us that they employed agency staff in response to staff absence and used a dependency tool to identify staffing need.

We found the service was not always safe as the service had been broken into twice in recent months and although some security measures had been taken further measures were required to make the service safe for people.

We made a recommendation to the provider to obtain expert advice to make the service secured.

The service demonstrated they recorded mental capacity decisions in people’s records and but did not in all instances record the best interest decision clearly to show it was the least restrictive option. However the service had made Deprivation of Liberty Safeguards applications appropriately and had requested reviews in a timely manner. Staff demonstrated they understood the need to obtain people’s consent and gave people choice.

Staff had received supervision from the deputy manager and had received a good standard of training from the training manager to equip them to undertake their work. Staff demonstrated to us they were knowledgeable about the people they supported.

We found overall three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take at the back of the full version of the report.

We observed people on the mental health unit having breakfast, we saw that a choice was offered. At weekend's people could have a cooked breakfast. People we spoke with all confirmed that the food was good.

Relatives and people we spoke to all confirmed there was enough staff. One relative said, 'there always appears to be enough staff on when I visit my mum.'

We saw the service completed several audits; we reviewed the infection control audit and mattress and couch audit.

We reviewed the fluid balance charts, turning charts. We saw that on the whole charts were being completed. Staff we spoke with were aware how much people should be drinking and the importance of recording as soon as people have had a drink.

At the inspection on the 5 June 2013 we found that where people did not have the capacity to consent, the provider acted in accordance with legal requirements. We saw that the manager had put systems in place to gain and review consent from people who lived in the home. We saw five documents that had to be completed before the person could commence on covert medication (medication hidden in food or drink). These documents involved all people who were involved in the person care, such as psychiatrist, doctor, relatives, home staff and pharmacist. This aimed to ensure that decisions taken were in the person's best interests. We could see how the covert medicine would be given and when the decision would be reviewed and by whom.

People told us that the home was kept clean and staff were aware of infection control polices and the importance of hand washing. One person told us "its kept spotlessly clean." Staff records were up to date and there was an effective recruitment and selection process for staff.

People who used the service and relatives were given the opportunity to discuss concerns in several ways through monthly group meetings or by the use of surveys. We saw that concerns and complaints had been acted on.

We saw that medication records were up to date and accurate and staff were appropriately trained in medication management. We found five people were on covet medication, some discussion had occurred with the multidisciplinary team but we saw no evidence in peoples care plans of any alternative methods that had been tried before the covert medication started. None of these people had received a capacity assessment.