Elreg House

Elreg House is a ‘care home.’ People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to provide accommodation and personal care for up to 32 older people, including those living with dementia. At the time of the inspection there were 30 people living at the home. Elreg House is a detached property in a suburban area of Shoreham. It has been adapted and extended from a domestic house. Accommodation is provided over two floors. The first floor can be accessed by a stairlift for those with mobility needs. All bedrooms were single apart from one which could be used as a double. Twenty-four bedrooms had an en suite toilet. People were observed using communal areas, which included a lounge, a conservatory and a dining room. There was a garden with seating for people.

At our last inspection on 22 March 2016 we rated the service Good. At this inspection we found the evidence continued to support the rating of Good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

The home was found to be clean and hygienic although we identified greater attention to cleaning was needed in two bedrooms where there was an unpleasant odour. The registered manager was aware of this and said action would be taken to address this. We have made a recommendation about this.

The provider ensured safe care was provided to people. Risks to people were assessed and measures taken to mitigate these. The premises and equipment were safely maintained. Checks were made to ensure staff were suitable to work in a care setting. Medicines were safely managed. Incidents or accidents were reviewed and action taken to reduce the likelihood of any reoccurrence. People and their relatives said they were satisfied with the standard of care provided.

The registered manager ensured current guidance and legislation was followed regarding people’s care and treatment. Staff were well trained and supervised. The staff felt supported and valued.

People’s nutritional needs were assessed and people were supported to eat and drink. People said they liked the food. Health care needs were monitored and referrals made to other services to ensure there was a coordinated approach to people’s care. Health care professionals said people received a good standard of care and that the staff worked well with health care services to meet people’s needs. 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 supported this practice.

People were treated with kindness, respect and compassion. People and their relatives said they were treated with respect. For example, one person told us, “The staff are lovely, they are affectionate and always speak to me with respect.” Care was individualised and people were able to make choices in their daily lives. People’s privacy was promoted.

People received personalised care which was responsive to their needs. Assessments and care plans were comprehensive. People’s care needs were reviewed and people, or their representative, were consulted. The provider identified and met people’s communication needs. The provider had an effective complaints procedure and people said they knew what to do if they had a concern. Whilst there no people in receipt of end of life care at the time of the inspection the provider had policies and procedures for this. Staff were trained in end of life care. Records showed people’s preferences and needs regarding end of life care were assessed and planned for.

The service was well led and provided person centred care. The registered manager was motivated and kept herself and the staff team updated with training and current practice guidance. The provider had a policy statement on promoting equality for all people and staff. People and their relatives’ views about the service were sought as part of the provider’s quality assurance process. There were comprehensive audits and checks on the quality and safety of the service with corresponding plans to make changes where this was identified. The registered manager was open to making improvements to the service.

Further information is in the detailed findings below.

As a result we undertook a focused inspection on 14 September 2015 to follow up on whether the required actions had been taken to address these concerns, and to see if the required improvements had been made. We found improvements had been made with some areas. However, despite meeting all legal requirements, further areas for improvement were identified in order to improve further some practices in relation to meeting people’s nutritional needs, ‘as required’ (PRN) medicines and the provider’s quality assurance framework. The overall rating for Elreg House remained as Inadequate and the service continued to be in Special Measures.

The purpose of special measures was to provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration. Services placed in Special Measures will be re-inspected again within six months. If sufficient improvements have been made, the service can come out of Special Measures and the overall rating can be revised. You can read the reports from our previous inspection, by selecting the 'all reports' link for (Elreg House) on our website at www.cqc.org.uk

We undertook this unannounced comprehensive inspection to look at all aspects of the service and to ensure that the areas that required improvement had been met, and that the previous improvements had been sustained. We found that they had, and the overall rating for Elreg House has been revised to good, the service has also come out of Special Measures. However, further areas were identified in order to improve some practices in relation to record keeping.

Elreg House is registered to provide accommodation with personal care for a maximum of 28 people. There were 27 people using the service on the day of our inspection. The home specialises in the care of older people with dementia type illnesses. It is situated in a residential area and provides accommodation over two floors.

A registered manager was 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 and associated Regulations about how the service is run.

Care plans gave information on how people wished to be supported and daily records showed what care had been delivered. However some care plans and daily records contained gaps in their recording, or were missing information. We also saw that records in relation to water temperatures, complaints and personal emergency evacuation plans (PEEPS) were not accurate, were missing, or contained omissions. We have identified this as an area of practice that needs improvement.

Improvements had been made since the previous inspection, and medicines, including PRN (as required) were managed safely and in accordance with current regulations and guidance. There were systems in place to ensure that medicines had been stored, administered, audited and reviewed appropriately.

Improvements had been made since the previous inspection, and people were encouraged and supported to eat and drink well. There was a varied choice of meals and people were able to give feedback and have choice in what they ate and drank. People were advised on healthy eating and special dietary requirements were met. People’s weight was monitored, with their permission. Health care was accessible for people and appointments were made for regular check-ups as needed.

Improvements had been made since the previous inspection, and people were involved in the development of the service and were encouraged to express their views. Staff were asked for their opinions on the service and whether they were happy in their work. They felt supported within their roles, describing an ‘open door’ management approach, where management were available to discuss suggestions and address problems or concerns. One member of staff told us, “The new manager has made a real difference here. She is approachable and listens”. The provider undertook quality assurance reviews to measure and monitor the standard of the service.

People were happy and relaxed with staff. They said they felt safe and there were sufficient staff to support them. When staff were recruited, their employment history was checked and references obtained. Checks were also undertaken to ensure new staff were safe to work with adults at risk. One person told us, “Yes, I have always felt safe here”. Staff were knowledgeable and had received training on safeguarding adults. Staff understood what action they should take if they suspected abuse was taking place.

People were being supported to make decisions in their best interests. The registered manager and staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).

Accidents and incidents were recorded appropriately and steps taken by the service to minimise the risk of similar events happening. Risks associated with the environment and equipment had been identified and managed. Emergency procedures were in place in the event of fire and people knew what to do, as did the staff.

People could choose how to spend their day and they took part in activities in the home and the community. People told us they enjoyed the activities, which included singing, exercises, films, arts and crafts and themed events, such as reminiscence sessions.

Staff had received essential training and there were opportunities for additional training specific to the needs of people. Staff had formal personal development plans, such as regular supervision meetings with their manager. One member of staff told us, “We get lots of regular training, I’m up to date”.

People felt well looked after and supported and we observed friendly and genuine relationships had developed between people and staff. One person told us, “The staff are friendly and helpful”. A relative added, “I am very happy with the care”. People were treated with dignity and respect, their privacy was upheld and they were encouraged to be as independent as possible.

People were encouraged to stay in touch with their families and receive visitors. Relatives were asked for their views about the service and the care delivered to their family members. Completed surveys showed families were happy overall and felt staff were friendly, welcoming and approachable. Residents’ and relatives meetings were held and people said they felt listened to and any concerns or issues they raised were addressed. A relative told us, “The manager is really good, we’re very pleased with the home. I have no concerns at all”.

During our previous inspection on 27 May 2014 we identified that people who used the service were at risk of receiving care or treatment that was inappropriate because the planning and delivery of care did not always meet their needs. We also found that the provider did not have an effective system to regularly assess and monitor the quality of service that people received. We set a compliance action and the provider wrote to us telling us how they would become compliant. Therefore, we focused our inspection on the standard of care and welfare provided to people who used the service and how the provider assessed the quality of the service they provided.

This is a summary of what we found:

We looked at nine care plans and associated records. We saw the plans had a consistent structure and detailed the care people required. All of the people we spoke with told us they were happy with the level of care provided. Their comments included 'it is very pleasant here', 'I'm happy with it all' and 'staff are very good and patient'.

We observed care in the communal areas of the home and saw staff interacting with people in a positive way. Staff engaged with people in a kind and caring manner. However, we did see two occasions where people's dignity was not respected by staff.

CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We spoke with the manager for the home who told us all of the service users in the home lacked capacity to make decisions. We found the manager and staff had an understanding of MCA and DoLS but did not always record their decision making and assessments. The home had coded locks on all of the outside doors, included the doors to the enclosed garden are. This meant people's liberty was restricted. We found that applications for DoLS authorisations had not been completed for people using the service.

The home had a dedicated activities coordinator and people were encouraged to take part in activities. During our inspection music was playing in the lounge area and we saw a person dancing with a member of staff.

People who used the service and their representatives were asked for their views about their care and treatment. Feedback questionnaires had been sent out to people and their relatives. We saw the results of the feedback from those questionnaires. These were positive with comments that included '[My relative] seems to have settled in so well, and staff are very caring'. One person had commented that they would like their breakfast served earlier. We looked at their care plan and saw that had now been implemented.

There was a staff meeting structure, where staff could raise any issues or concerns and the provider took account of complaints and comments to improve the service.

People's personal records were not always accurate and fit for purpose. We looked at the medication administration record (MAR) charts for the home and saw that in 24 out of the 27 we looked at, there were several gaps where care staff had not completed the record fully. We also found that care plans were incomplete and did not contain up to date information regarding people's care needs.

We saw there was a structured quality assurance process in place to regularly assess and monitor the quality of the service people received. However, the auditing of the MAR charts was not robust.

We saw that people's records were kept in a secure location, and staff were able to locate them when required. Therefore, people's records and personal information were kept confidential.

We spoke with three people who used the service and three visiting relatives. During the inspection, we spoke with the provider, registered manager, deputy manager, four care workers, a member of housekeeping, the laundry assistant and two visiting healthcare professionals. We also obtained feedback from a mental health professional after the inspection.

Below is a summary of what we found. The summary describes what people who used the service and the staff told us, what we observed and the records we looked at. If you want to see the evidence supporting our summary please read the full report.

Is it safe?

We found, in most cases, people were protected from bullying, harassment, avoidable harm, abuse and breaches of their human rights.

People were treated with dignity, kindness and respect. One person who used the service told us, 'It's lovely here.'

The Care Quality Commission (CQC) is required by law to monitor the operation of the Deprivation of Liberty Safeguards. We found the location to be meeting the requirements of the Deprivation of Liberty Safeguards (DoLS).

Staff demonstrated an understanding of mental capacity and DoLS, but policies and procedures specific to the service were not in place to provide guidance and support.

Systems were not in place for staff to learn from incidents, accidents and near misses

Staffing levels were sufficient to meet the needs of people using the service.

People received care from suitable qualified and trained care workers.

It is effective?

People had their needs assessed and individual care plans were devised. Before anyone joined the service, a pre-admission assessment took place.

People received appropriate support from healthcare professionals when required. These included referrals to other professionals such as general practitioners (GPs) and district nurses.

Systems were not in place to monitor, assess and improve the quality of the service. Feedback was not regularly obtained from people who used the service, their relatives and visiting healthcare professionals.

We found the premises to be clean and tidy.

It is caring?

People were supported by kind and attentive staff.

People looked happy and content in the company of care staff.

The service had a warm and friendly atmosphere.

People were dressed in accordance with their individual lifestyle choice. We saw that the service encouraged people to decorate their room accordingly and to bring items of importance.

Care workers understood people and their needs and these needs were also reflected in people's care assessments.

Is it responsive?

People had their needs assessed and support was sought where necessary.

Staff and visitors we spoke with felt comfortable in raising any concerns.

There was a complaints policy and procedure in place if people or their representatives were unhappy, but we could not see that complaints were handled appropriately and in a timely manner.

People had access to activities. We found that activities were limited at times and not always meaningful to the person using the service.

Is it well-led?

The service worked well with other agencies.

A registered manager was in post that provided leadership, support and hands on care.

Emergency plans were in place but the service had no qualified first aiders.

Care workers were motivated, caring, well trained and supported and there was clear leadership at all levels within the home.

Staff told us they were clear about their roles and responsibilities.

During our inspection we spoke with the provider, registered manager, deputy manager, two care workers (one of whom was a supervisor), a cleaner and a visiting health professional. We also spoke with two relatives. As the people who used the service were unable to express their views, we used a method of structured observation to help us understand their experience.

We found that people's care needs were assessed and care plans developed and delivered to meet their individual needs. We saw that people were moved safely when they required assistance to do so. A relative told us, 'I've no complaints the way they are looked after. I've noticed kindness to all of them.'

We found that appropriate standards of cleanliness and hygiene were maintained. A care worker told us, 'I think cleaning has improved since I first started. Over the weeks there has been a focus on it. They have employed more cleaners who are very good. They clean this place like they would their own home.' A relative said, 'Standards have definitely improved.'

We found there were sufficient numbers of staff to meet people's needs. A relative commented, 'We see more staff on duty.' A care worker told us, 'There seem to be enough staff. Shifts get covered.'

We found that staff sought people's consent before providing care, and acting in their best interests when they lacked capacity to consent. The provider said, 'We ask individuals, whatever their capacity if they say no, they say no'.

People told us they were happy in the home. One said the staff were kind and that they had, 'No upsets at all'. People's needs were assessed and care plans made to meet those needs. However, we found the recording in plans was inconsistent and placed people at risk of inappropriate care. We had concerns over moving and handling practices.

We had some concerns regarding the cleaning of the home. We saw improvements had been made in the management of linen since our last visit.

Although additional staff had been recruited since our last visit we still found there were insufficient staff to fully meet people's needs. A care worker said, 'There's not enough staff to supervise; we're all off doing personal care'.

People felt safe at the home and staff knew how to identify and manage any suggestion of abuse. A visiting health professional felt, 'People here are safe and well cared for'.

The home had recently undergone extensive refurbishment and redecoration. Whilst we received feedback that this had been a difficult and disruptive time, people were pleased with the improvements that had been achieved.

When we arrived at Elreg House we had concerns about the level of cleanliness at the home and observed some poor infection control practices. These were highlighted to the provider who took immediate remedial action. The feedback from visitors and staff told us that this impression was not typical of the standards observed by other people who visited the home. We spoke with five visitors, who each independently confirmed that they had never had concerns about the hygiene of the home.

We found evidence that Elreg House employed a stable team of staff who worked well together. People we spoke with described staff as "excellent" and said that their relatives were "well looked after" and felt "very comfortable with staff." Two people we spoke with queried whether there were enough staff. Our evidence indicated that Elreg House did not always have enough staff on duty to fully manage a busy home.