Archived: Elmsleigh Care Home

The service is required to have a registered manager and at the time of our inspection a registered manager was not in post. The manager who was in charge of the day-to-day running of the service had applied to become the registered manager. At the time of this inspection their application was being processed. A registered manager is a person who has registered with the CQC 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.

We carried out this unannounced inspection of Elmsleigh Care Home on 25 October 2016. At this comprehensive inspection we checked to see if the service had made the required improvements identified at the inspection of 14 June 2016.

In June 2016 we found the premises and equipment were not properly maintained. There were two shower rooms, where the showers had been removed, and the floors were stained and dirty. There were three bathrooms that were not in full working order, including water that was too hot to be safely used by people living at the service. An unlocked boiler room, accessed through a bathroom, put people at risk of harm because the room had hot pipes and electrical equipment. There was broken equipment stored around the premises, including in areas identified at a previous inspection in September 2015.

At this inspection while we found some improvements had been made to the premises and the environment there were still areas of concern. There were communal bathrooms and en-suite bathrooms that either did not have hot water or had water that was too hot with the risk of scalding people. One shower room had a wall mounted electric bar heater approximately three feet immediately opposite the shower which meant water could come in contact with the heater. There was no hot water available in the kitchen on the day of the inspection. While the door to the boiler room, accessed through a communal bathroom, was locked the door leading into the boiler room in a corridor was not locked. Three bedroom self closing fire doors were seen wedged open by furniture and a suitcase in one case. These issues put people at risk of harm.

Most of the broken equipment that had previously been stored around the building had been removed. However, we did find an unused pressure mattress, unnamed continence pads and a ladder stored in the entrance area to a toilet used by people. The premises were warm throughout the inspection, except for one corridor which was cooler than the rest of the building. The communal areas were clean and odour free. However, some people’s bedrooms were not clean and had strong incontinence odours. Several toilets and bathrooms did not have paper towels, soap or waste bins to enable effective hand washing and infection control. All of the above created an environment that was not homely or pleasing for people to live in.

In June 2016 we had concerns about the safety of two people living at the service who had been assessed as being at high risk of falls and ‘unsafe if left unobserved’. At this inspection we found action had been taken to help reduce the risk of harm for these two people. One person’s health had deteriorated and they were less mobile than they had been. They had also been provided with head protection, to protect their head if they did fall. The other person had been given funding to have individual care. While this had helped to reduce their falls this person could still suddenly get up and attempt to walk. However, there was no risk assessment to provide instructions for staff about assisting them to mobilise safely as they were very unsteady on their feet.

At this inspection we found some people did not receive consistent or good care because systems to provide for, and monitor, people’s needs were inadequate. This included systems for food and fluid charts, hourly observation charts, monitoring people’s weight and checking the settings on pressure relieving mattresses. These inadequate systems had led to poor outcomes for some people. For example, some people had been assessed as needing hourly observations by staff because they were cared for in bed. These checks were had been introduced to try to ensure they were safe, their personal care needs were met and they had everything they needed. Despite these checks being in place for two people their needs had not been met. Staff had not provided personal care, made the environment safe or respected these individuals’ dignity.

The provider had not taken adequate action to address how staff could provide appropriate care for people identified as refusing care and who were at risk of self-neglect. The service had not monitored these people’s repeated refusal of care or sought any advice or guidance from external professionals in meeting their needs. Staff had not been given sufficient direction and guidance about how to meet these people’s complex needs. We observed that staff lacked knowledge and confidence in how to provide care for these people. Following our inspection visit we ‘alerted’ these two people to Cornwall Safeguarding to ensure they were protected from further harm.

Some people had been assessed as being at risk from developing skin damage due to pressure. Pressure mattresses were in place for these people. However, the mattresses were not monitored to ensure that they were correctly set for the person using them. If pressure mattresses are not set to the weight of the person using them there is a risk that pressure damage to their skin will not be prevented. Where people had been assessed as needing to be re positioned regularly, to help reduce the risks of pressure damage, this was being completed for most people. However, one person was not routinely re-positioned or checked by staff.

We found that slings used when people needed to use a hoist, of different sizes appropriate to peoples’ different sizes and weights, were shared between people. Net pants, used to wear over continence pads were shared. Continence pads were supplied to meet each individual person’s assessed continence needs to ensure people used the right size and type. However, it was clear from supplies left in communal bathrooms and other areas that these pads were also being used between people. These practices did not respect people's dignity and human rights and represented institutional ways of working.

The care we saw provided to people during the inspection was often task orientated rather being than in response to each person’s individual needs. Some people living in the service had complex behavioural needs and limited communication. Care plans did not always give staff guidance about how to communicate with people, especially where people refused care and were at risk of self-neglect. We observed some staff had little interaction with people with complex communication needs. Bedrooms for some people did not have any identification on the doors such as a number, their name or a picture to support people in recognising their own bedrooms. This meant it could be difficult for people living with dementia to orientate around the building and find their room.

Some people were at risk of losing weight due to having a poor diet. Food and drink monitoring was in place for these people, but records were not being checked so no action had been taken to address any concerns. Where records stated that people needed to be weighed weekly this was not being carried out. Some people had sustained substantial weight loss and it was not clear what action had been taken to help the person maintain a healthy weight. This meant some people were at risk of their needs not being met in relation to their weight, and food and fluid intake because this was not being sufficiently monitored.

Where people needed assistance or prompting from staff to eat their meals this was not actioned in a timely manner. Some people did not show any interest in eating nor had any insight into it being mealtime. These people were left, sat in the same seat in which they had spent their day, with their meals in front of them uneaten, even though most needed encouragement to eat. Hot drinks were provided throughout the day. However, some people didn’t drink them and staff took them away when they got cold. People who needed assistance from staff to eat did not always have hot food. Staff helped more than one person during the lunch period. However, meals came from the kitchen together so some meals were cold by the time a member of staff was available to help some people to eat.

When we observed the lunchtime period we found there was little interaction between people and staff. Staff who assisted people to eat their meals did so without any real conversation. There were three bank staff on duty on the day of the inspection. We noticed that they needed guidance from permanent staff. While they were willing and completed the tasks assigned to them competently they were reluctant to initiate interactions with people, due to being unfamiliar with people’s needs.

The management of medicines was not robust. We identified some concerns with the recording processes used by staff when administering and managing medicines. There were gaps in records which meant it was not always clear that people received their medicines as prescribed. Two peoples’ medicines were found in their rooms, having not taken them. One person had them on their bedside table and in another room medicines were strewn on the floor. However, when

The service is required to have a registered manager and at the time of our inspection a registered manager was not in post. The manager in charge of the day to day running of the service had submitted an application to CQC for the registered manager position. A registered manager is a person who has registered with the CQC 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.

We carried out this unannounced inspection of Elmsleigh Care Home on 14 June 2016. At this comprehensive inspection we checked to see if the service had made the required improvements identified at the inspection of 8 September 2015. In September 2015 we found the premises and equipment were not properly maintained. Some areas of the building did not have hot water due to problems with the boiler. There was broken equipment stored around the building, including in areas used by people such as lounges and bathrooms. There were two dirty shower rooms where the showers had been removed and the space was being used to store broken equipment. Toilet facilities in both these shower rooms were being used by people.

We also found there were not enough working hoists and wheelchairs to meet people’s needs. There were insufficient adaptations to the premises to support people with dementia.

At this inspection we found that signage to help people with dementia to orientate independently around the building was in place. Additional hoists and wheelchairs were available in the service and staff told us there was enough suitable equipment to meet people’s needs. The two shower rooms, identified at the inspection in September 2015 as being dirty, had been partially re-decorated although the floors where the showers had been were still dirty and stained.

There was still broken equipment stored around the premises, including in the two shower rooms identified at the last inspection. There were three bathrooms where water was either at the incorrect temperature or taps that were not working. An unlocked boiler room put people at risk of harm because the room had hot pipes and electrical equipment. During the afternoon we found the heating along one corridor of the premises was not working. After we advised the deputy manager, the thermostat was altered, and by end of the inspection heating had been restored to that area. These concerns potentially put people at risk of harm and created an environment that was not homely or pleasing for people to live in.

We had concerns about the safety of two people living at the service who had been assessed as being at high risk of falls and ‘unsafe if left unobserved’. Both people had moved from other services where they had been funded for individual support. The funding for additional staff had not transferred with them and managers had not put any additional staff on duty each day. The numbers of staff on duty were not enough to provide individual care for each of these people. Records showed that both persons A and B had fallen on a number of occasions. At the time of our inspection one person was in hospital and the other person had recently returned from hospital. Both had been admitted to hospital with injuries from falls at the service. Insufficient action had been taken to mitigate the risk of harm to these two people.

Advice was sought from external healthcare professionals but not always acted upon. For example, records for one person showed that in February 2016 a discussion took place between the service and an external healthcare professional. This discussion suggested the service should provide protective headwear because the person was at high risk of hitting their head when falling. This had not been actioned and suitable protective headwear had not been obtained despite this person continuing to have frequent falls and being at risk of hitting their head.

Care plans were personalised to the individual and gave clear details about each person’s specific needs and how they liked to be supported. These were reviewed monthly or as people’s needs changed.

Where people were assessed as being at risk of skin damage due to pressure, appropriate equipment such as hospital beds and pressure relieving mattresses were in place. Care plans detailed where people needed to be regularly re-positioned and how often staff should carry out this task. Staff monitored the food and fluid intake for people who were assessed as being at risk being undernourished and dehydrated.

Safe arrangements were in place for the storing and administration of medicines. People received their medicines at the prescribed time.

Staff completed a thorough recruitment process to ensure they had the appropriate skills and knowledge. Staff knew how to recognise and report the signs of abuse.

Management and staff had a good understanding of the Mental Capacity Act 2005 (MCA). Where people did not have the capacity to make certain decisions the management and staff acted in accordance with legal requirements under the MCA. Staff applied the principles of the MCA in the way they cared for people and told us they always assumed people had mental capacity.

There was a management structure in the service, where the responsibilities of each role were defined by the organisation. Staff had a positive attitude and they told us they felt supported by the management. Comments from staff included, “Can approach them easily [management]”, “I am happy, we have been through a rough patch, it is better now” and “There is good communication with managers, we have lots of support and good handovers each shift.”

People and their families were given information about how to complain. People told us they knew how to raise a concern and they would be comfortable doing so. Where complaints had been made appropriate action had been taken to resolve the concerns raised to the person’s satisfaction. There were effective quality assurance systems in place to make sure that any areas for improvement were identified and addressed.

We identified breaches of the regulations. You can see what action we have told the provider to take at the back of the full version of the report.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records. If you want to see the evidence to support our summary please read the full report.

Is the service safe?

People were treated with dignity and respect by staff. We spoke with six people living in the home and they told us they felt safe living there.

Elmsleigh Nursing Home had policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DOLS). There was evidence the home considered the impact of any restrictions put in place for people that might need to be authorised under the Deprivation of Liberty Safeguards.

People were protected from the risk of infection because appropriate guidance had been followed. People were cared for in an environment that was safe, clean and hygienic. Incidents and accidents were recorded and learning from these events was used to change practice to reduce the risk of harm to people.

People’s needs were not always met because care records did not accurately reflect their current needs. Vital information for staff to follow to ensure people’s safety and welfare was not always recorded in care records. There was not always enough staff on duty to meet the needs of the people living at the home.

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines. People did not always receive their medicines at the time they needed them.

We have asked the provider to tell us what actions they intend to take to meet the requirements of the law in relation to people’s care, staffing levels and medicines.

Is the service effective?

During our inspection we observed staff caring for people. It was clear from our observations and from speaking with people that staff had a good understanding of people’s needs.

People’s health and care needs were assessed and mobility and equipment needs had been identified where required. Staff we spoke with and observed showed they had good knowledge of the people they supported.

Is the service caring?

People’s individual care plans recorded their choices and preferred routines for assistance with their personal care and daily living. We saw staff provided support in accordance with people’s wishes.

During our inspection we spoke with six people who used the service and observed staff interaction with people. People we spoke with told us staff were caring and attentive to their needs. We observed staff responding to people in a kind and caring manner.

Is the service responsive?

The home provided some regular group activities such as arts and crafts, singing sessions and exercises. Most people we spoke with did not express a view about the activities on offer.

Elmsleigh gave clear information to people about how to complain. We looked at the home’s complaints policy and saw a copy of the complaints procedure in the home. At the time of our inspection the home had not received any complaints.

Is the service well-led?

The home worked with external health professionals to ensure people’s health needs were met.

The provider had an effective system to regularly assess and monitor the quality of service that people received. The provider asked people who used the service, their families and professionals for their views about their care and treatment and used any feedback to improve the service.

We observed staff helping people in a discreet manner and speaking to people with respect. We saw call bells were answered very promptly.

We saw care plans were detailed and directed staff as to the care and support people needed. They had been regularly reviewed. We saw a range of activities were available.

We saw meals were well presented and care workers were available to assist people as required. We saw the four week rolling menu and saw there were always choices available at each meal.

Medicines were handled appropriately, kept safely, safely administered and were disposed of appropriately.

Staff told us training was provided, and records confirmed they had received supervision. The manager told us annual appraisals were not yet in place but were planned.

The home was spread over two floors. At the time of the inspection the first floor was not accessible to people using the service as the whole floor was being refurbished