Echelforde is a care home without nursing for a maximum of 50 older people, some of whom are living with dementia. There were 46 people living at the home at the time of our inspection.

The inspection took place on 19 April 2017 and was unannounced.

There was 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 and associated Regulations about how the service is run.

At our last inspection 18 May 2016 we found the provider was breaching legal requirements in relation to safe care, consent and assessments. Staff did not always use appropriate moving and handling techniques, which put the people they were supporting at risk. People’s capacity to make decisions had not been assessed, which meant the provider could not be sure their care was being provided in the way they wished. Some staff did not keep confidential information about people’s care secure. Care plans had not always been fully completed, which meant staff did not have all the information they needed about the people they cared for.

The provider sent us an action plan telling us how they would make improvements in order to meet the relevant legal requirements.

At this inspection we found the provider had taken action to address these concerns. Staff provided care in a safe way and used appropriate equipment when supporting people to transfer. Staff ensured that discussions about people’s care were kept confidential. People were encouraged to make decisions about their care. Where people lacked the capacity to make informed decisions, staff had followed an appropriate process to ensure decisions were made in their best interests. Staff had consulted people and their relatives about their care plans and recorded information about people’s life histories, important relationships and interests.

People felt safe at the service and when staff provided their care. There were enough staff on each shift to meet people’s needs. Risks to people had been assessed and measures put in place to reduce these risks. Staff understood safeguarding procedures and were aware of their responsibilities should they suspect abuse was taking place. People were protected by the provider’s recruitment procedures. There were plans in place to ensure people would continue to receive their care in the event of an emergency. Health and safety checks were carried out regularly to keep the premises and equipment safe for use. People’s medicines were managed safely.

People were supported by staff that had the skills and experience they needed to provide effective care. Relatives said staff knew their family members’ needs well and provided consistent care. Staff had an induction when they started work and access to ongoing training, supervision and support.

People enjoyed the food provided and told us there was a good choice of meals. People had opportunities to give their views about the menu and their suggestions were implemented. The registered manager had implemented measures that had improved the support people received to maintain adequate nutrition and hydration.

People’s healthcare needs were monitored effectively and people were supported to obtain treatment if they needed it. Referrals were made to healthcare professionals if staff identified concerns about people’s health or well-being. Any guidance about people’s care issued by healthcare professionals was implemented and recorded in people’s care plans.

Staff were kind and caring and treated people with respect. They were attentive to people’s needs and demonstrated compassion in their approach. People had developed positive relationships with the staff who supported them and they enjoyed their company.

People’s needs had been assessed before they moved into the home and wer

The inspection took place on 18 May 2016 and was unannounced. Three inspectors carried out the inspection.

Echelforde provides accommodation and personal care for up to 50 older people, some of whom are living with dementia. There were 43 people living at the service at the time of our inspection. There are five units, each accommodating up to ten people.

There was 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 and associated Regulations about how the service is run.

At our last inspection in October 2015 we found breaches of Regulation 9, Regulation 12, Regulation 17 and Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued warning notices in relation to Regulation 12, Regulation 17 and Regulation 18. We required the provider to have met the warning notices by 15 January 2016.

The provider also sent us an action plan telling us how they would make improvements in order to meet the relevant legal requirements by 15 January 2016.

Following the last inspection the service was placed into special measures. This inspection found the quality of care people received had improved sufficiently to change the service rating from inadequate to requires improvement. This meant the service was removed from special measures.

Although action had been taken to address the concerns identified at our last inspection further improvements were needed.

At this inspection, we found the number of staff on duty reflected the staffing rota. People, relatives and staff told us this had improved the care people received. People told us they no longer had to wait unacceptable lengths of time to receive their care. Staff said they had more time to spend with people.

Although the numbers of staff deployed had increased since our previous inspection, staff told us people would benefit from a further increase in staff. The registered manager told us the provider was actively recruiting to enable additional staff to be deployed on each unit.

The provider had taken action to maintain the safety of people who tried to leave the service. The security of the premises had been improved.

The leadership of the service and the support provided to staff had improved. A new manager had been appointed and had achieved registration with the CQC. The registered manager was clear about the areas in which the service needed to improve and recognised the importance of seeking the views of people, relatives and staff to achieve improvements in the service.

People, relatives and staff told us the registered manager had improved communication with them. They said they had been encouraged to contribute their views and that these were listened to. Quality monitoring checks had been more effective in identifying areas of the service that needed improvement.

Staff did not always use appropriate moving and handling techniques when supporting people. Equipment used to transfer people was not being used as identified in one person’s care plan.

The majority of staff were caring in their interactions with people but some staff did not act in a way that maintained confidentiality.

Opportunities for people to take part in activities had increased and were provided in the service’s day centre. However, there were limited opportunities to access activities for people who chose to stay in their individual units.

Assessments and care plans did not record details about people’s lives before they moved into the service, which meant staff did not have the information they needed to engage with people about their life history or their interests and hobbies.

Staff understood safeguarding procedures and were aware of their responsibilities should they suspect abuse was t

We spoke with six people who used the service. They were complimentary about the staff and the care they received. As we were unable to verbally communicate with some people we spent time observing the interactions between the people and staff. We observed these to be positive. We observed a member of staff who knelt down to speak to people in chairs. This ensured they had eye contact. They spoke in a soft voice to ensure that people were not startled.

Staff explained how they ensured people consented to their care and treatments. We were told support was given when people accepted. Staff would not rush people but go at their pace and with their consent.

Care plans and risk assessments were held on computers. These had been updated regularly and reflected the care needs identified.

Staff were aware of the procedures to report faulty or unsafe equipment. The provider ensured that maintenance contracts were in place for larger pieces of equipment.

The provider carried out appropriate checks to ensure staff were of good character and had the necessary skills and experience before they were employed.

Quality audits took place regularly and the manager sought the views of the people who used the service.

The people using the service were unable to tell us their experiences at the home as they had varying cognitive impairments, associated with Alzheimer’s or dementia.

The people using the service were unable to tell us their experiences at the home as they had a diagnosis of dementia. We spoke to seven relatives to seek their views.

We were told the staff were really kind and helpful but they were concerned at the sudden departure of the manager and wondered what had happened.

Most of the relatives said they had noticed deterioration in the activity provision and two people told us they wished their family members could go outside even into the garden.

Comments were made about the offensive smells within the home and the lack of a redecoration and refurbishment programme. One person told us that a wardrobe had fallen on her mother and a chair had collapsed when she had sat in it.

Three family members told us that their relative had lost personnel items whilst at the home and finding these items had not been addressed.

The inspection took place on 14 and 18 October 2015 and both visits were unannounced. Two inspectors were present on 14 October 2015 and one inspector carried out the visit on 18 October 2015.

Echelforde provides accommodation and personal care for up to 50 older people, some of whom are living with dementia. There were 48 people living at the service at the time of our inspection. There are five units, each accommodating up to ten people. Two of the units accommodate people with more complex support needs.

There was 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 and associated Regulations about how the service is run.

There were not enough care staff deployed at all times to meet people’s needs. This meant that people had to wait when they needed support and that their care was often interrupted. The lack of care staff was a particular problem at weekends. On a weekend shortly before our inspection, there were so few care staff on duty that non-care staff, including domestic and activities staff, were called in to provide support.

There were concerns about the management oversight of the service as the staffing rota showed that there were insufficient staff on duty to provide people’s care on the weekend in question but no action had been taken to address this. The provider had a quality monitoring system but this was not effective as it had failed to identify that there were insufficient staffing levels to provide safe care.

There were concerns that staff had not received appropriate leadership and that the provider had not responded to the concerns raised by people, relatives and staff. Some staff said they felt the management of the service was not fully aware of the impact staff shortages were having on people and staff. They said they had raised their concerns about staffing levels and high vacancy rates but no action had been taken to address their concerns.

The lack of care staff had reduced the activities available to people as activities staff were often used to support care staff. People told us that planned activities did not always take place and they did not have the opportunities they would like to go out.

The provider had not implemented adequate measures to maintain the safety of people who tried to leave the service. Two people had expressed their wish to leave the service and tried to do so on a daily basis. The risks presented to these people had been identified but the steps taken to mitigate these risks were ineffective as both people had been able to leave the service unaccompanied within the last two months.

Staff had not received regular supervision and appraisal, which meant they did not have opportunities to discuss their support and professional development needs. Some staff said they had never had a supervision meeting with their manager and none of the staff we spoke with had had an annual appraisal since they started work. All staff attended an induction when they started work and had access to ongoing training. The provider’s recruitment procedures were robust, which helped to ensure that only suitable staff were employed.

The registered manager understood their responsibilities in relation to the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and training had been provided for staff in this area. Assessments had been carried out to determine whether people had capacity to make decisions and people’s best interests had been considered when decisions that affected them were being made. People said that staff asked for their consent before supporting them and our observations confirmed this. DoLS authorisations had been applied for where necessary, which meant that people’s care was provided in the least restrictive way.

People’s needs, including their dietary needs, were assessed when they moved into the service. People told us that they enjoyed the food provided and that they could have alternatives to the menu if they wished. Staff monitored people’s health and supported them to make a medical appointment if they became unwell. Medicines were managed safely.

Staff understood safeguarding procedures and were aware of the provider’s whistle-blowing policy. People knew how to make a complaint and we found that any complaints received had been investigated and responded to in line with the complaints procedure.

People received their care from familiar staff and had positive relationships with the staff who supported them. Staff were kind and caring and treated people with respect. People were asked for their consent to the care they received and applications for DoLS authorisations had been made where people were subject to restrictions in the provision of their care.

We identified a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

The overall rating for this provider 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.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

Following the inspection, the provider told us they had begun to take action to address the concerns we identified. We will check the actions taken by the provider at the next inspection.