Elburton Heights

Elburton Heights is a care home that can accommodate up to 85 people who require nursing or residential care. The home can provide care to people who might be living with a physical disability, a mental health need or with dementia. The home has four separate units: Maple provides nursing care; Willow provides nursing care to people living with dementia; Birch provides residential care and Sycamore provides residential care for people living with dementia. Each unit had its own communal facilities. At the time of the inspection 54 people were living at the home.

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

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's nutritional needs were met, and risks associated with foods and fluids were managed well. People told us they enjoyed the food and we saw people had an enjoyable dining experience.

People had opportunities and access to a variety of activities to prevent social isolation. Social activities met people's individual needs, and people told us they enjoyed the activities provided and they felt they were inclusive.

People's care plans reflected individual needs with clear guidance for staff to follow to ensure people received person centred care. People were positive about the care they received and told us staff were caring. During our observations we saw staff being kind and caring to the people they supported.

Staff regularly assessed the risks associated with people's care and well-being and took appropriate action to ensure the risks were managed and that people were safe. People received their medicines as prescribed and were supported effectively by knowledgeable and trained staff.

The service was well-led by a new registered manager who was focusing on improving people's care and developing staff skills. A lot of significant changes had been implemented to support effective team working and improve people's outcomes. The provider had quality assurance systems in place to monitor the quality and safety of 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 19 November 2019).

At our last inspection we recommended that the provider strengthened its food and drink strategy to ensure people's nutrition and hydration needs are being closely monitored and met.

At our last inspection we recommended that the service sought guidance from dementia care specialist organisations about engaging people in meaningful activities, and to improve their records to demonstrate people's engagement.

At our last inspection we recommended the service reviewed people's care records to ensure they provide detailed information about people's care needs and their preferences.

At this inspection we found the provider had acted on these 3 recommendations and had made improvements.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

The service was clean and fresh, staff carried out a regular cleaning schedule. Regular infection control audits took place and actions had been followed up when required. An additional cleaning schedule had been introduced to ensure robust measures to reduce infection risks, including additional tasks such as cleaning of any regular touchpoint surfaces.

The provider had robust systems to ensure safe admissions, including only allowing new admissions after a confirmed negative result of the Covid-19 test. The provider had also assessed the environment, with consideration given where to allocate people should they need to isolate.

Safe arrangements were in place for professionals visiting the service. This included a confirmed negative lateral flow device test result, proof of vaccination against COVID-19, hand sanitisation and wearing personal protective equipment (PPE).

The provider ensured there was a sufficient stock of personal protective equipment (PPE)

Staff had received training on infection prevention and control guidance. This included updates on the use of PPE and how to put it on, take it off and dispose safely.

Staff's competency around infection control and PPE was checked regularly to prevent staff complacency. There was a designated area for donning and doffing PPE. There was signage all around the service on donning and doffing PPE and handwashing.

There was a comprehensive contingency plan of what to do in case of an outbreak. The management team completed risk assessments to assess and mitigate risks in relation to COVID-19. Managers were supported by the provider who supported quality and assurance audits on the service.

Elburton Heights is a care home that can accommodate up to 85 people who require nursing or residential care. The home can provide care to younger and older people who might be living with a physical disability, a mental health need or with dementia. The home has four separate units: Maple provides nursing care; Willow provides nursing care to people living with dementia; Birch provides residential care and Sycamore provides residential care for people living with dementia. Each unit had its own communal facilities. At the time of the inspection 57 people were living at the home.

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

At the previous inspection we found the home was not providing safe care that met people’s needs and preferences, this included receiving medicines as prescribed. People were not treated respectfully, and their dignity was not upheld. There were insufficient numbers of staff to meet people needs and provide them with opportunities to engage in social activities meaningful to them. Staff had not received the training they required to fulfil their role. The environment was not suited to people’s needs, particularly those living with dementia. Governance systems were ineffective in assessing, monitoring and improving the service. We identified nine breaches of regulations.

At this inspection we found significant improvements had been made and the home was no longer in breach of the regulations. However, we have made three recommendations for improvement.

People and relatives told us the home was now being well managed and said they felt safe. One person said, “I am really safe here because staff take great care of me 24/7.” People were supported by kind, caring and respectful staff. One person said, “The staff are absolutely caring – the best I’ve ever had.” In relation to the management of the home, a relative said, “It has really improved in the last six months. The new manager is doing an excellent job in improving Elburton Heights.”

Risks associated with people’s care needs had been assessed and management plans were in place to mitigate these. Care plans guided staff about people’s needs, although some required more detail to ensure people received consistent care in a way that met their preferences. Tools used to monitor people’s support around eating and drinking, continence and skin integrity were not always complete or reviewed by senior staff or nurses. However, we found this did not have a negative impact on people’s health, safety and well-being.

People told us they enjoyed the food provided. People’s comments included, “This is the best food I’ve eaten in a care home” and “What I like here is that if you don’t like the meal you can have something else without a fuss.” Risks associated with eating and drinking, such as choking and poor nutrition, had been assessed and guidance sought from healthcare professionals.

Medicines were being managed safely and people were received their medicines as prescribed. There were suitable systems in place for the storage, ordering, administering, monitoring and disposal of medicines.

Staff training had significantly improved with the majority of staff having completed all mandatory training required by the provider. Staff demonstrated a good understanding of people’s needs and preferences. However, we found further consideration was needed to support people to engage in activities meaningful to them. For example, we found staff did not turn off the radio when putting on the television, and the sound from both were in competition. Also, in Sycamore, the residential dementia unit, improvements were required to the environment and with providing more opportunities for people to be socially engaged.

Sufficient staff were employed in all four units, although some relatives felt staffing at weekends could be improved and we discussed this with the manager. On both days of the inspection we saw people being supported in a timely way, staff spent time with people in the lounge rooms, and the morning medicines rounds were completed promptly. Staffing arrangements were consistent throughout the week, however, the home did rely on some agency staff to cover sickness and holidays. Staff recruitment practices were safe.

Rating at last inspection: The rating at the last inspection was Requires improvement overall. The report was published on the 24 September 2018. This service had been rated repeat Requires improvement at the previous two inspections and we had met with the provider to discuss our findings and their subsequent actions.

Why we inspected: We inspected because we received concerns about people’s care from a variety of sources. CQC have been liaising closely with the local safeguarding adults team. The areas of concern were used to inform our planning for this inspection.

Enforcement: Following our last inspection we found four breaches of regulations. There was a lack of appropriate records, which placed people at risk of receiving inappropriate care. Not all staff were receiving appropriate training, supervision and appraisal, necessary to carry out their

duties. The provider has failed to ensure people received safe care and treatment and risks to people's health and safety had not been fully assessed and measures to reduce risks were not fully effective. The provider had failed to have effective governance systems and quality assurance processes to assess, monitor and drive improvement. At our last inspection we told the provider to provide us with an action plan about how they would ensure compliance with the regulations and by when.

This was a repeated 'Requires Improvement' rating so we met with the provider in December 2018 for reassurance that there would be improvements. We placed two conditions on the location registration that:

1. The Registered Provider will complete monthly audits of staff training and supervision, service users’ records relating to their current care and risks, medicine management, audits relating to the environment: and write a report on what you have found, with the actions you intend to take as a result of these audits.

2. The registered provider will send the commission a monthly report on the 1st working day of each calendar month the findings and actions of the points above.

Despite this, at this inspection this rating had deteriorated to ‘Inadequate’.

At this inspection we found action had not been taken to address all the concerns and breaches of regulations found at the previous inspection and we found these areas had deteriorated and were inadequate as well as finding further concerns.

People’s experience of using this service

• The quality of people's care raised serious concerns, mainly related to the nursing units known as Willow and Maple where 39 people were living.

• People that were dependent on staff to pre-empt and meet their needs were being failed by the service.

• People were not receiving care that was fully safe, effective, caring, responsive to their needs and well-led.

• The service is now judged to be inadequate in keeping people safe, providing effective care, as well as a lack of caring and responsive support, and leadership.

• Most people living on the nursing units, Willow and Maple, were living with dementia or conditions affecting their communication and/or understanding. Therefore, they were unable to comment on their direct experience of living at Elburton Heights. Relatives and staff all told us how they had concerns and had brought them to the manager and staff on the nursing units but had not seen an improvement.

• There was a severe lack of staffing numbers to enable people’s needs to be met on Willow and Maple which resulted in poor care and people’s basic needs not being met.

• Risks in relation to people’s care and lifestyle were not known fully by staff, assessed, understood and managed in a way that kept them safe. For example, in particular to ensure adequate nutrition and hydration, safe management of falls, effective skin pressure area care, safe manual handling and caring, and safe management of people’s behaviour which could be challenging for staff. Monitoring records were poor with many gaps which meant we could not be sure people were safe or having their needs met consistently.

• People did not live in an environment that was dementia friendly, homely or promoted their dignity and independence.

• There was poor infection control management particularly in relation to the maintenance and cleanliness of equipment.

• The culture of the service did not always respect and promote people’s rights, dignity and independence. There was a lack of understanding about people’s needs due to a lack of training and competency checks, poor communication between management, nurses and care workers and care plan information was not used to help facilitate person centred care.

• There was a lack of care, engagement and stimulation on the nursing units to ensure people lived a good quality life. Activities offered did not take into account individual interests and preferences or consider individual’s abilities with the focus being on the activity itself.

• The leadership and auditing of the service had not been robust and had failed to identify and act quickly on the concerns we found in relation to practice, the environment and culture of the service. The nursing units lacked leadership because nurses and care staff did not have time, and often nurses were from agencies and lacked knowledge of people’s needs. This meant that people had continued to receive a service that was not fully safe, effective, caring or responsive to their needs.

• The provider had failed to act in a timely way on areas of concerns found at the last inspection or within their own audits.

• The service is now judged to be inadequate in keeping people safe, providing effective care, as well as there being a lack of caring and responsive support, and being inadequately led.

• We did see some positive interactions during the inspection, with staff being kind, friendly and patient when completing tasks, especially on the residential units.

• People seemed to enjoy the food they were offered.

We note that the majority of this report reflects on serious failings found on the nursing units Willow and Maple. We also inspected the residential units and found there to be overall good care although there were also issues with the use of the dependency tool and a lack of ‘as required’ medicines information for staff to follow. In contrast to the predominant examples in the report people and relatives said on the residential units that they were happy with their care. The environment was homely and comfortable, staff were visible and there were regular activities.

Follow up:

We were so concerned during the first day of our inspection that we spoke to Plymouth City Council about our initial findings and practices we had concerns about. We asked the manager to immediately source additional staff for the nursing units and ensure that staff had the information they needed to support people and ensure they were safe. Following the feedback from our fourth day of inspection we sent an initial summary of our findings which had raised serious concerns about people’s safety on the nursing units. We asked the provider to send us a detailed action plan by 25 March 2019 to assure us that the issues were being addressed as a matter of urgency, which we received. This provider action addressed our initial findings and gave some reassurance that these issues would be addressed as priority. The local authority, safeguarding team and quality assurance and improvement team (QAIT) are all involved in monitoring the progress, reviewing, and assessing the people most at risk.

The overall rating for this registered service is 'Inadequate'. This means that it has been placed into 'Special Measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• 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.

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.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded. We will have contact with the provider and registered manager following this report being published to discuss how they will make changes to ensure the service improves their rating to at least Good.

Elburton Heights is a care home that can accommodate up to 85 people that require nursing or residential care. At the time of the inspection 69 people were living at the home. The service is split into four units that offer either nursing services or residential care. Two units look after people living with dementia; one is a nursing unit and one is a residential unit. There is a further nursing unit and another residential unit.

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.

The service did not have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The service was currently being overseen by a registered manager of another Harbour Healthcare service with the support of the regional manager because the service was in the process of recruiting a new manager for Elburton Heights.

When we completed our previous comprehensive inspection on 27 and 28 April 2017 we found the areas of effective and responsive and well led required improvement with a breach of Regulation in responsive.

At that inspection we found concerns that people were not being assessed in line with the Mental Capacity Act 2005 as required. We also found that though some people had care plans in place to reflect their current needs, people living with dementia were not having their needs planned for. We recommended that the provider looked at this to ensure they were following current guidance. Some people’s records of their daily life were not robust enough to demonstrate the care given. We had recommended the provider reviewed this. People were at risk because the provider's systems to monitor the quality of the service were not fully effective and had failed to identify or address areas where improvements were needed. At that time the leadership, governance and culture did not ensure staff had sufficient information to ensure people's needs were fully met and staff were not well supported to enable them to consistently and safely deliver good quality care.

This inspection in July 2018 was a comprehensive inspection that looked at all areas of the service again to check the service had addressed the concerns from April 2017. We found the service had made improvements in some areas while other areas now required improvements. At this inspection we rated the service as Requires Improvement.

People's capacity to make important decisions about their lives had now been assessed in accordance with the Mental Capacity Act 2005 (MCA). The provider and staff understood their role with regards to ensuring people’s human and legal rights were respected. For example, the Mental Capacity Act (2005) (MCA) and the associated Deprivation of Liberty Safeguards (DoLS) were understood by the provider. They knew how to make sure people, who did not have the mental capacity to make decisions for themselves, had their legal rights protected and worked with others in their best interest. People’s safety and liberty were promoted.

People’s care and support was based on legislation and best practice guidelines, helping to ensure the best outcomes for people. People’s legal rights were upheld and consent to care was sought.

People’s care records were detailed and personalised to meet individual needs. Staff understood people’s needs and met them. People were not all able to be fully involved with their support plans, therefore family members or advocates supported staff to complete and review people’s support plans in their best interests. People’s preferences were sought and respected. Care plans held full details on how people’s needs were to be met, considering people’s preferences and wishes. Information held included people’s previous history and any cultural, religious and spiritual needs.

The manager overseeing the service and provider had put new systems in place to oversee the running of the service and check its quality. This manager and provider had monitoring systems which enabled them to identify good practices and areas of improvement. However not all issues had been picked up by these monitoring systems. For example, some areas of the service were void of home comforts including sofas, chairs, tables and lamps. The service was monitored by the management team to help ensure its ongoing quality and safety. However not all issues we found with the medicines system and infection control guidance had highlighted areas of concern. The manager and provider immediately arranged additional training for staff and had met with staff to help resolve these issues.

Staff and professionals said the current management team were approachable and had made many improvements since starting to oversee the service a few months ago when the registered manager left. However, people, relatives, staff and professionals raised concerns about not having a suitable stable registered manager in post. The provider stated they were currently in the process of the recruitment of a new manager who would register with us. Staff said the current manager overseeing the service was involved in the day to day running of the service and this was evident when we walked around the large service and they knew all the people currently living there.

The provider had an ethos of honesty and transparency. This reflected the requirements of the duty of candour. The duty of candour is a legal obligation to act in an open and transparent way in relation to care and treatment.

People were mostly safe at the service. People, who were able to, said they felt safe living at the service. One person said; “I’ve always felt safe here.” A relative said; “We feel that she is safe here, she certainly wasn’t before at home.” Staff and healthcare professionals all agreed that people were safe. However, we found that at times people in one area did not always have staff on hand in case of an emergency.

People’s risks were assessed, monitored and managed by staff to help ensure they remained safe. Risk assessments were completed to enable people to retain as much independence as possible. However, one person was found to have a significant pressure ulcer. This was currently being managed by the tissue viability nurse. The manager overseeing the service, who had previously worked at the service, said they had been very disappointed at finding this person had sustained a pressure ulcer. They had now put additional systems in place to help ensure people were better protected including putting full pressure relieving equipment in place they needed to keep them safe. However, we also found that some pressure relieving mattresses were not working as they should be. For example, one was broken and another was set at the incorrect rate. We also saw staff moving people in wheelchairs without any attached foot plates and asking elderly people to ‘raise their legs’ when moving them around the building. We also found that some people’s repositioning charts had not always been completed, or stated when people should be repositioned and how often. These issues were reported to the manager and immediate action was taken to help to rectify them and keep people safe.

People mostly received their medicines safely by suitably trained staff. However, the new medication system being used placed people at risk due to lack of some staffs’ understanding and not following the correct process. For example, at the end of the month not all people’s current medication had been carried over to the next month. Therefore, there was a risk if the staff administering the medicines were not regular employed staff, for example agency staff, or staff were not aware that this medicine was continuing. If the medication did not get carried over on the system it stated it had been “discontinued” on their record. This placed people at risk of not receiving all their medicines. For example, one person’s pain relief medicine had not been carried over. This also meant the staff had to complete the medicine round before uploading these forgotten medicines. Staff then administered the missed medicine which therefore meant people were receiving their medicines in two parts and needed to wait for their medicines. This also meant the medicines round was completed late which had a knock-on effect for people requiring medicines at a set time apart from the previous dose. The new system highlighted if people had not received their prescribed medicines and the medicine system showed if a medicine round had not been 100% completed. However, we found that not all staff checked that it had been completed and that all people had received their medicines as required. We found that one person did not receive their prescribed medicine at 7am as needed. Therefore, all their medicine which needed to be taken at least 2 hours after the 7am medicine now needed to be given later. Good infection control procedures were not always practiced by staff administering medicines. For example, some staff did not wear gloves when handling medicines and taking people’s blood sugar levels. Some people required ‘as and when medicine’ and medicine charts and care plans did not all hold a protocol in place to provide staff with the information they needed to ensure people got the pain relief they needed and when they needed it.

People lived in a service which had been designed and adapted to meet their needs. People lived in an environment that was clean and hygienic. Parts of the environmen

Elburton Heights is registered to accommodate up to 85 older people. The service is split into four units that offer either nursing services or residential care. Two units look after people living with dementia; one is a nursing unit and one is a residential unit. There is a further nursing and residential unit. When we inspected 64 people were living at the service.

A registered manager was employed to manage 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. They were supported by a deputy manager, administrator and unit leads.

Where people were not able to consent to their care, staff did not always ensure people were assessed in line with the Mental Capacity Act 2005. Also, people living with dementia did not have a dedicated care plan in place for staff to understand how each person’s dementia journey was affecting them. We have recommended the provider refers to current guidance on best practice in respect of care planning for someone living with dementia.

When we looked at the records of how people passed their day, what activities they had completed and how staff had met their care needs, we found these to be incomplete, lacking personal detail and had gaps. Also, we found that different units were holding information of people’s care in different ways. We have recommended that the provider ensures they are recording people’s day to day lives in line with current guidance.

The registered manager and provider completed regular audits to check aspects of the service were running well. These had identified some but not all of the issues we identified. Action was not then recorded as to how this omission was being addressed.

People, relatives and staff were involved in giving feedback on the service. Everyone felt they were listened to and any contribution they made was taken seriously.

People told us they were safe and happy living at Elburton Heights and were looked after by staff who were kind and treated them with respect, compassion and understanding.

People felt in control of their care. People’s medicines were administered safely and they had their nutritional and health needs met.

People could see other health professionals as required. People had risk assessments in place so they could live safely at the service. These were clearly linked to people’s care plans and staff training to ensure care met people’s individual needs. The identifying and assessing of people’s individual risk was inconsistent.

People’s care plans were written with them, were person centred and reflected how people wanted their care delivered.

People were provided with enough to eat and drink to maintain their welfare. We have recommended the provider reviews how they monitor people’s nutritional and hydration needs.

Staff knew how to keep people safe from harm and abuse. Staff were recruited safely and underwent training to ensure they were able to carry out their role effectively. Staff were trained to meet people’s specific needs. Staff promoted people’s rights to be involved in planning and consenting to their day to day care.

Activities were provided to keep people physically and cognitively stimulated. People’s faith and cultural needs were met.

We found a breach of regulation. You can see at the end of the full report what action we have requested the provider take