Archived: Elm Royd Nursing Home

Prior to this inspection concerns had been raised by the local authority and clinical commissioning group (CCG) regarding the clinical management of the home. These concerns had been discussed with the provider who agreed to a voluntary suspension on admissions to the home and additional nursing staff were provided by the CCG in April 2017 to work alongside the home’s own staff providing clinical support and guidance. On 1 June 2017 the additional nursing staff supplied by the CCG were withdrawn at the request of the provider following the transfer of eight people from Elm Royd to other services. The voluntary suspension on admissions was still in place when we carried out this inspection.

Elm Royd Nursing Home is registered to provide nursing and residential care to up to 50 older people, some of who may be living with dementia. On both days of the inspection there were 29 people living in the home, 28 who required nursing care and one person who required personal care. Accommodation is provided on two floors in single rooms with en-suite facilities. There are communal areas on both floors.

At the time of the inspection the home did not have a registered manager. A manager had registered with the Care Quality Commission in January 2017, however they left their post in April 2017. A manager from one of the provider’s other services was managing the service when we inspected. 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.

Although people we spoke with told us they felt safe we found there were insufficient staff to meet people’s needs and keep them safe. For example, on the second day of the inspection we saw some people did not receive their morning medicines until 12.30pm as there was only one nurse on duty when previously there had been two. The night staff told us they had been told to get more people up to help the day staff and were concerned as this meant people had to be washed and dressed very early in the morning. We saw periods of up to an hour when no staff were present in communal areas.

Risks were not well managed which placed people at risk of injury or harm. For example, we saw one person had a severe choking episode after eating bacon, fried bread and sausage when they were supposed to have a soft diet because of swallowing difficulties. Staff were not aware this person required a soft diet.

Medicines were not safely managed which meant we could not be assured people were receiving their medicines as prescribed.

Safe recruitment processes were in place and new staff received induction, however we found this often took place several weeks after the staff member had started work. Staff received ongoing training however this was not always kept up to date and supervisions had lapsed although the manager told us they had a plan to address this.

We saw current certificates showed the safety of the gas supply, portable appliance testing, electrical wiring and fire systems. However, weekly checks of emergency lighting, door guards and water temperatures had not been completed since 10 May 2017.

Staff were aware of safeguarding procedures and were confident any abuse they reported would be dealt with appropriately.

The requirements of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) were not being met as we found conditions which had been applied to DoLS authorisations had not been complied with.

Most people said they enjoyed the food although we found the meals identified on the menus were not always been served. We found people’s dining experiences differed depending upon whether they were on the ground floor or the first floor. For example on the ground floor people were offered a choice of food and drink which did not happen on the first floor.

Where people’s food and drink intake was being recorded there were no systems in place to review these records to ensure people were receiving sufficient to eat and drink.

People praised the staff and said they were kind and caring. However, we observed practices which showed a lack of respect for people and compromised their privacy and dignity.

There was conflicting information about people’s care needs and care plans did not always reflect accurately the care people required, putting people at risk of receiving inappropriate or unsafe care. People had access to healthcare services.

People told us they knew how to make a complaint and we saw records which showed complaints had been investigated and the complainant had been informed of the outcome.

We found there was a lack of consistent and effective management and leadership which coupled with ineffective quality assurance systems meant issues were not identified or resolved. This was evidenced by the continued breaches we found at this inspection. We identified seven breaches in regulations – staffing, safe care and treatment, dignity and respect, nutrition, person-centred care, consent and good governance. Following the inspection we made safeguarding referrals to the local authority safeguarding team and had discussions with the CCG and local authority commissioners. Due to the seriousness of our concerns the CCG and the local authority took immediate action to provide additional support into the home and worked with the provider to ensure all people accommodated in the home were moved to alternative accommodation by 16 June 2017.

The Care Quality Commission is considering the appropriate regulatory response to resolve the problems we found. 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 therefore remains in ‘Special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Elm Royd Nursing Home is registered to provide nursing and residential care to up to 50 older people and people who may be living with dementia. There were 38 people living in the home on the first day of the inspection and 39 on the second.

The service has not had registered manager since September 2013. However, at the time of this inspection there was a manager in place and their application for registration was being considered by the Commission. 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 last inspection was in April 2016 and during that visit we found that overall improvements had been made since October 2015 when we rated the service as inadequate and placed it in special measures. In April 2016 we found one breach of regulation in relation to the safe management of people’s medicines. This inspection was carried out to check if the required improvements had been implemented and sustained. We found they had not.

People’s medicines were not managed safely and we could not be assured people were receiving their prescribed medicines properly.

Risks to people’s health, safety and welfare were not properly identified or managed. For example, we found two free standing heaters with very hot surface temperatures in use. Action was not taken to address this risk until we brought it to the attention of the home manager. In another example, we found when people had pressure relief equipment, such as mattresses, in place there was no information in their care records to show the correct settings.

We found there were not enough staff on the first floor to meet people’s needs. When we raised this with the management team on the first day of the inspection they told us they had just carried out a review of people’s dependency which showed they needed more staff on the first floor. However, when we returned on the second day the staffing had not been increased.

People who used the service told us they felt safe and the staff we spoke with knew how to recognise and report abuse. The provider had robust recruitment procedures in place and new staff received induction training. However, after induction we found staff did not consistently receive the training and support they should have to carry out their duties effectively.

We found people were not always supported to meet their nutritional needs. When people’s food and drink intake was being recorded there was no evidence the records were being checked to make sure people were having an adequate diet.

The home was working in accordance with the requirements of the Mental Capacity Act and Deprivation of Liberty Safeguards. People were asked for consent and their wishes were respected. When people lacked capacity decisions made in their best interests were recorded.

People had access to the full range of NHS services. People were supported to plan how they wanted their end of life care to be delivered.

We saw some good interactions between staff and people living in the home. However, we also saw examples of practices which did not respect people’s dignity. Although there was a programme of activities people with more complex needs did not always get the support they needed to meet their social needs.

We found people’s care records did not always reflect their current needs and care was not always delivered in line with people’s assessed needs.

There was a complaints procedure in place. People who lived in the home told us they had no complaints. Relatives who had raised concerns with the manager told us they were satisfied with the action taken.

People who lived in the home and their relatives were given the opportunity to share their views of the service by way of meetings and surveys. However, we found no action had been taken in response to issues raised in surveys people had completed in September 2016.

We found the provider did not have good governance systems in place which would enable them to monitor, assess and improve the quality of the services provided.

During this inspection we found the provider was in breach of six regulations. There were Regulation 12 (Safe care and treatment). Regulation 9 (Person centred care), Regulation 10 (Dignity and respect), Regulation 14 (Meeting nutrition and hydration needs), Regulation 17 (Good governance) and Regulation 18 (Staffing). The Commission is currently considering the appropriate regulatory response to the issues we identified.

The overall rating for this service is ‘Inadequate’ and the service is therefore in special measures. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures

Elm Royd Nursing Home is registered to provide nursing and residential care to up to 50 older people and people who may be living with dementia. There were 31 people using the service at the time of inspection.

At the time of the last inspection in October 2015 the service had a contract with Calderdale Clinical Commissioning Group (CCG) to provide seven intermediate care beds. These places were used to provide people with additional support on discharge from hospital, before they could return home; or sometimes as an alternative to a hospital admission. The contract had been for a limited period of time and when we carried out this inspection on 19 April 2016 it had just come to an end. The last person to use the service under this arrangement was discharged home on the day we inspected.

The service has not had registered manager since September 2013. 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 the time of our inspection had been in post since December 2015. They told us they had been employed by the provider in November 2015 as a ‘crisis’ manager to provide short term management and support to services which were failing to meet the required standards. They said they were in the process of recruiting a permanent manager for Elm Royd and would remain at the home until a new manager had been appointed and settled in.

At the last inspection in October 2015 we found the provider was in breach of a number of regulations. Some of these were continued breaches from the previous inspection in August 2014. The breaches of regulation were in relation to safeguarding people from abuse, the safe management of medicines, meeting people’s nutritional needs, respecting people’s privacy and dignity, delivering appropriate care which met people’s needs, dealing with complaints, cleanliness and infection control, the maintenance of the premises and equipment, reporting incidents and governance. We told the provider they must take action to improve the service and issued six requirement notices and four warning notices. The purpose of this inspection was to check the provider had taken the required actions.

Overall we found improvements had been made but more needed to be done so that we could be assured people would consistently receive care which was safe and took account of their individual needs and preferences.

We found people were safe and staff knew how to recognise and report abuse. The required checks were carried out before new staff started work and this helped to protect people from the risk of being cared for by staff who were unsuitable to work in a care setting. Staff were supported to carry out their roles by means of training, supervision and appraisals. The staff were caring and compassionate and were able to tell us how people liked their care and support to be provided. However, we found some aspects of the environment did not promote people’s dignity. In addition, we found people’s care records were not always kept secure which meant confidentiality was not always assured.

We found the staffing had improved, new staff had been employed and people told us the reduction in the use of agency staff had helped to improve communication and the continuity of care. There were generally enough staff available to meet people’s needs in a timely way. However, there were some busy times during the day, such as meal times, when this was more difficult. We made a recommendation that staffing numbers should be kept under review as people’s needs changed.

Improvements had been made to the way people’s medicines were managed and the risk had been reduced. However, we found the provider was still in breach of this regulation as further improvements were needed to ensure people’s medicines were consistently safely managed.

The home was clean and equipment such as hoists was available and maintained. We found some parts of the home would benefit from refurbishment and more needed to be done to create a ‘dementia friendly’ environment.

We found risks to people’s health; safety and welfare were identified and managed. The manager had identified that more needed to be done to make sure there was learning from accidents and/or incidents to reduce the risk of recurrence.

People had adequate amounts of food and drink and were offered choices. However, improvements were needed to make sure people living with dementia were supported to make informed choices.

People’s care needs were assessed and their care plans provided clear information about the support they needed. People had access to a range of NHS services to help make sure their health care needs were met. People were asked for their consent before care and treatment was provided and when they were unable to give consent decisions were made in their best interests. We found the service was working in accordance with the requirements of the Mental Capacity Act 2005 and people were not deprived of their liberty unlawfully. However, in one case we found the care records did not accurately reflect the actions being taken to comply with the conditions of a Deprivation of Liberty Safeguards authorisation.

There were some activities but more needed to be done to support people to engage in meaningful activity and occupation. People were able to have visitors at any time which suited them and could see their visitors in private.

People told us they know how to make a complaint and said the manager always acted quickly to deal with any concerns they raised.

Improvements had been made to the way the safety and quality of the services provided was monitored. However, these need to be maintained so that we can be assured people will consistently experience care which is which is safe and effective and takes account of their individual needs and preferences.

We found one breach of regulation. You can see what action we told the provider to take at the back of the full version of the report.

Since then, the provider told us they had addressed all of these issues. We made this inspection to see what improvements had been made.

We saw that records relating to people's nutritional needs had improved. We also saw that the quality of food available and the service of food had improved. People we spoke with said they enjoyed the food at the home.

We saw processes for auditing the quality of service had been improved and had been followed.

Complaints had been addressed and investigated appropriately.

We spoke with one person who was visiting their relative. They told us they thought the home was "good" they also said "meals are good - a lot better than they were before." We spoke with several people who lived at the home some of whom, due to complex care needs, were not able to tell us about their experiences. Those who were, told us they were "comfortable", "well looked after" and, when asked about the staff one person said "they are great".

We made this visit to see what actions had been taken.

Since our last visit a new manager had been appointed and we found that compliance had been achieved in care and welfare, safeguarding, safety and suitability of premises and staffing. Whilst we noted some improvements relating to nutrition and assessing the quality of service provision, further improvement was needed.

During this visit we found that complaints had not been managed effectively and that record keeping had not always been effectively maintained.

We spoke with a visiting relative who said that there had been changes recently, all of which were "for the better".

Visiting clergy also commented to us that they had seen a positive difference in staffing levels.

Many of the people we spoke with were not able, due to complex care needs, to tell us their opinions. We did observe however, that people appeared well cared for and that staff were caring in their approach.

Staff we spoke with told us that there had been improvements and they felt that the new manager involved them in the running of the home. Some staff expressed concerns about the quality and quantity of food provided to people who lived at the home.

"There are not enough staff".

"We don't have anything to do".

"I spend all my time waiting for help".

"The food is sometimes good but sometimes it's rubbish".

"I can't get a drink because there are no staff around to ask, I'm very dry".

One person visiting expressed their concerns to us about the care at the home. Some other visitors told us that they were happy with the care their relative had received.

We found that people were not getting the care they needed due to insufficient numbers of staff on duty. Staff were not available to meet people's needs in relation to safety or nutrition.

The quality monitoring systems of the home had failed to identify issues relating to people's safety and records were not stored safely.

As a result of our inspection where we concerned about the care and safety of the people who lived at the home, we made a whole service safeguarding referral to the local authority