About the service:

Elizabeth House is a residential care home that provides personal and nursing care to for up to 108 people aged 65 and over. At the time of the inspection there were 59 people living at the service.

Rating at last inspection:

The rating of the service was ‘Inadequate’ (Last report published 14 September 2018) and the service was placed into ‘Special Measures’. This is where the care expected falls below this standard and is judged to be inadequate. The service is kept under review and is inspected again within six months. We identified five breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014. This related to the level of care people received, risk and medicines management, staffing levels, staff training, induction and supervision; and governance.

Why we inspected:

This was a planned inspection based on the rating at the last inspection of ‘Inadequate’.

People’s experience of using this service:

Significant improvements were noted since our last inspection to Elizabeth House in July 2018. Although people’s comments about the care provided was variable, our observations relating to the level of care people received was much improved. The atmosphere within the service was relaxed and calm. Staff told us the support they received from the registered manager and other senior management team members was much better and they were valued and supported. The registered manager and other senior management team members were visible within the service, were clear about their roles and responsibilities and aware that further improvements were still required.

Risks for people were identified but staff did not clearly record how risks to people’s safety and wellbeing were to be reduced and the actions required to keep people safe. Some people were at risk of having their safety compromised. This was because people who were at risk of swallowing difficulties and choking were not being properly supported.

Care planning arrangements did not ensure all of a person’s care needs were recorded. Staff were aware of people’s end of life care needs but these were not recorded. People enjoyed the activities provided but stated there were occasions when they were bored and there was nothing for them to do. Improvements were required to ensure people who remained in their bedroom were not socially isolated.

People told us staff did not always have sufficient time to give them the care and support they needed. The deployment of staff during the inspection was appropriate and there were enough staff to meet people’s needs.

Staff received regular training opportunities to enable them to meet people’s needs. Newly employed staff received a comprehensive induction and staff told us they felt valued and supported. Recruitment arrangements were robust to ensure the right staff were recruited.

People were protected by the provider’s prevention and control of infection procedures.

Sufficient food and drink was available to people throughout the day. Regular monitoring and review was carried out for people at nutritional risk to ensure their dietary needs could be met.

People experienced positive outcomes regarding their health and wellbeing and had access to healthcare services. The service worked collaboratively with other services and agencies.

People’s capacity to make day-to-day decisions had been considered and assessed and the provider was working within the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Follow up:

We will continue to monitor intelligence we receive about the service until we visit again in line with our inspection programme and scheduling. If any concerning information is received we may inspect sooner.

Elizabeth House provides accommodation and personal care for up to 108 older people and people living with dementia. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Our previous comprehensive inspection to the service was on 11 and 19 December 2017, 9 and 18 January 2018. The overall rating of the service at that time was judged to be ‘Good’. A focused inspection was completed on 9 and 10 April 2018 to review the domains of ‘Safe’, ‘Effective’ and ‘Well-Led’. The inspection was prompted in part by a specific incident. ‘Safe’ was judged as ‘Requires Improvement’ and ‘Effective’ and ‘Well-Led’ were judged as ‘Good’. No breaches of regulation were highlighted.

This inspection was completed on 26, 27, 28, 30 July 2018 and 7 August 2018 and was unannounced. There were 100 people living at the service.

We took urgent action to restrict admissions to the service and placed several conditions on the provider's registration because we were concerned about people's immediate safety.

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.

Since our last inspection in April 2018 and following a serious incident at the service in July 2018, the registered manager had resigned. Following their resignation, the registered provider made the decision for an existing registered manager from within the organisation to manage Elizabeth House. 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 registered manager has applied to be registered at Elizabeth House.

Quality assurance checks and audits carried out by the registered provider and former registered manager were not robust, as they did not identify the issues we identified during our inspection and had not identified where people were placed at risk of harm and where their health and wellbeing was compromised. The registered provider and management team of the service had not taken appropriate steps to ensure they had sufficient oversight of the service whi

The inspection took place on the 9th and 10th April 2018, the first day was unannounced.

Elizabeth House is a care registered to provide care for up to 107 residents, some of whom may be living with dementia. On the day of our inspection 95 people were living at the service.

The service was last inspected in December 2017 and was rated overall good. We undertook this inspection in response to concerns raised about people’s safety. This was a focussed inspection to review safe, effective and well-led. No risks, concerns or significant improvement were identified in the remaining Key Questions through our on-going monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

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. Elizabeth House provides care to people on four separate units within one large building over two floors.

The service has a registered manager. 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.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. Staff assessed risk to people and put plans in place to keep people safe. Some risk assessments needed to be more detailed on how to support people. Staffing levels needed to be consistently maintained to ensure people had prompt support with their needs. People were cared for safely by staff that had been recruited and employed after appropriate checks had been completed. Medication practices were safe and dispensed by staff who had received training to do so. There were systems in place to minimise the risk of infection and to learn from accidents and incidents.

People were safeguarded from the potential of harm and their freedoms protected. Staff were provided with training in safeguarding adults from abuse, Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice.

People had sufficient amounts to eat and drink to ensure that their dietary and nutritional needs were met. The service worked well with other professionals to ensure that people's health needs were met. People's care records showed that, where appropriate, support and guidance was sought from health care professionals, including a doctor, district nurse and speech and language therapist. The environment was appropriately designed and adapted to meet people’s needs.

The registered manager had a number of ways of gathering people’s views; they held regular meetings with people and their relatives and used questionnaires to gain feedback. The registered manager carried out quality monitoring to help ensure the service was running effectively and worked in partnership with other stakeholders to continually improve care.

The Inspection took place on 11, 19 December 2017 and 9, 18 January 2017 and it was unannounced. At the last inspection, the service was rated good. At this inspection, the service remains good.

Elizabeth House is a ‘care home’. People in care homes receive accommodation and or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and we looked at both during this inspection. The service is registered to care for up to 108 older people, some of whom may be living with dementia, a physical disability and/or a sensory impairment. The service does not provide nursing care. There were 107 people living in the service when we inspected.

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 2008 and associated Regulations about how the service is run.

People received safe care and support. Staff had a good understanding of how to protect people from the risk of harm. They had been trained and knew how to support people with their mobility needs and what to do in an emergency. There were sufficient staff that had been appropriately recruited to ensure they were suitable to work with vulnerable people. The medication system and practice was good and ensured that people received their medication as prescribed. Staff had received training in infection control and knew to wear protection clothing. The environment was clean, safe and hygienic.

People’s care and support needs had been fully assessed to ensure their diverse needs could be met. They, together with their families had been fully involved in the process and people's care plans had been regularly reviewed. Staff knew the people they cared for well, were well trained and supported and knew how to provide effective care.

People received the support they needed with food and drink. They were offered a good choice of meals and were supported to eat healthily. Staff helped people with their healthcare needs and worked together with other professionals to ensure that people received appropriate healthcare.

The service worked in line with other legislation such as the Mental Capacity Act 2005 (MCA) to ensure that people had as much choice and control over their lives as possible. People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice

People were cared for by staff who were kind, caring and respectful. They told us they felt they mattered and staff listened to them. Staff demonstrated a good knowledge of the people they cared for. People and their families were kept actively involved in their care and support. Advocacy services were available if people needed them. An advocate supports a person to have an independent voice and enables them to express their views when they are unable to do so for themselves.

People received personalised care that was tailored to their individual needs and kept under review to ensure it reflected any changes. The service offered people a range of activities both in the service and out in the local community. People were encouraged and supported to maintain their personal relationships with family and friends. The registered manager supported people in using technology such as computer tablets and mobile phones. They told us of their plans to introduce SKYPE so that people could see their loved one when talking with them.

People and their relatives told us they were able to raise concerns and complaints with staff and management. They felt their complaints were listened to and acted upon. Complaints had been fully investigated and actions had been taken to prevent a re-occurrence.

This inspection took place on 14 and 21 March 2016 and 8 April 2016 and it was unannounced.

The service provides care and support for up to 108 people some of whom may be living with dementia. There were 107 people living in the service on the first day of our inspection.

At the last inspection in July 2015 we asked the provider to take action to make improvements to staffing levels and to ensure that people were treated with dignity and respect. We had concerns about the lack of towels, flannels and crockery which led to people not being treated with dignity and respect. At this inspection we found that improvements had been made and that staffing levels had improved and there were sufficient supplies of towels, flannels and crockery.

There was a manager in post who was in the process of applying to be registered with CQC. 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.

People received their care and support in a way that ensured their safety and welfare. There were now sufficient numbers of staff who had been safely recruited, were well trained and supported to meet people’s assessed needs. People received their medication as prescribed and there were safe systems in place for receiving, administering and disposing of medicines.

The manager and staff had a good understanding of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and had made appropriate applications when needed.

Staff knew how to protect people from the risk of harm. They had been trained in safeguarding people and had access to guidance and information to support them with the process. Risks to people’s health and safety had been assessed and the service had care plans and risk assessments in place to ensure people were cared for safely.

People had sufficient amounts to eat and drink to meet their needs and individual preferences. Their healthcare needs were monitored and staff sought advice and guidance from healthcare professionals when required. People’s care needs had been fully assessed and their care plans provided staff with the information needed to meet their needs and to care for them safely.

Staff knew the people they cared for well and were kind and caring towards them. They ensured that people’s privacy and dignity was maintained at all times. People participated in activities of their choosing and were encouraged and supported to express their views and opinions. People were able to receive their visitors at any time and their families and friends were made to feel welcome.

People were confident that their concerns or complaints would be listened to and acted upon. There was an effective system in place to assess and monitor the quality of the service and to drive improvements.

This inspection took place at 6.15am on 17 July 2015 and was unannounced.

The service provides care and support for up to 108 people some of whom may be living with dementia. There were 106 people living in the service on the day of our inspection.

At our previous inspection in November 2014 we had concerns about the way communal space had been used. People had been crowded into one lounge when another lounge was empty. The lounge was noisy and people had found it difficult to hold a conversation because of this. At this inspection we found that improvements had been made and people used all of the available communal space.

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 2008 and associated Regulations about how the service is run.

There were insufficient staff on duty to meet people’s needs. Staffing levels had not been appropriately assessed to take into account people’s individual needs and staff and time required to support people safely and ensure their wellbeing.

People were not being treated with dignity and respect. Staff used unacceptable and unsafe practices due to the lack of appropriate body washing materials This also posed an infection control risk.

This inspection took place on 14 November 2014 and was unannounced.

Our previous inspection in May 2014 found concerns with how people were involved in their care planning, gave consent to their care, the numbers of staff available and how the service was managed. The service sent us an action plan detailing how it would address these issues. At this inspection we found improvements had been made.

The service is required by the Care Quality Commission (CQC) to have a registered manager. At the time of this inspection the previous registered manager had left. The manager in place on the day of our inspection had applied to the CQC to be registered. 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 provides care and support for up to 108 people. Some people living in the service are living with dementia.

People told us they felt safe living in the service. We observed staff providing care in a caring and respectful manner.

There were sufficient staff on duty to meet people’s needs. Staff had been trained and had the skills and knowledge to provide support to the people they cared for. They understood the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards which meant they were working within the law to support people who may lack capacity to make their own decisions.

People were supported with their interests and a choice of group activities were provided to encourage people to become involved and prevent social isolation. Some areas of communal space were seen to be under utilised while others were seen to be quite crowded.

People told us they knew how to complaint. The service had a clear complaints procedure in place which was displayed in the reception. We saw that complaints had been recorded and investigated.

The provider had a system in place to monitor the quality of the service. Where shortfalls were identified action plans with timescales for completion were in place.

As part of our inspection we visited Bluebell and Poppy units. On the day of our inspection there were a total of 108 people living at Elizabeth House.

During our inspection we spoke with eight people who used the service and several relatives. We also spoke with 12 staff members and the deputy manager.

We looked at 11 people's care records. We also looked at the provider's arrangements for obtaining, and acting in accordance with, the consent to care and treatment for people who used the service. In addition, we looked at medication practices and procedures, the provider's arrangements to ensure people who used the service received sufficient nutrition and hydration, staffing levels and; the provider's arrangements to monitor the quality of the service provided.

Observations of the provider's arrangements in relation to dignity, privacy, respect and the delivery of care for people living at Elizabeth House were undertaken within both units.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

People told us that they liked living in the service and felt safe.

People’s privacy, dignity and independence were respected. However, we found that people’s views and experiences were not always taken into account in the way the service was provided and delivered in relation to their care. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to respecting and involving people who used the service.

Where people did not have the capacity to consent, the provider had not acted in accordance with legal requirements. We found that not everyone had had their capacity to make day-to-day decisions assessed. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to consent to care and treatment.

We found that people who used the service were protected against the risks associated with the unsafe use and management of medicines.

The provider was not able to demonstrate that there were sufficient numbers of staff available for the needs of the people living at Elizabeth House. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to staffing.

Is the service effective?

Appropriate arrangements were in place to ensure that people who used the service received regular support and access from a variety of health and social care services and professionals.

We found that people who used the service were supported to have adequate nutrition and hydration.

Is the service caring?

People told us that they received the care they needed. People told us that they were happy living at Elizabeth House.

People who used the service had a care plan in place which detailed their specific care needs and the support to be provided by staff.

Is the service responsive?

Our observations during the inspection showed that visiting times were flexible.

We found that there were appropriate arrangements in place pertaining to complaints management.

Is the service well-led?

The provider was not fully able to demonstrate that there were suitable systems in place to assess and monitor the quality of the service provided. None of provider's systems had highlighted that there were gaps in relation to consent to care and treatment and staffing levels. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance.

People living in Elizabeth House and their families were mostly happy with the level of care and support offered. People told us: "I am comfortable here, the staff are kind," "The food here is good, the home is clean and most of the staff are very kind to my [relative]. They are as happy here as they would be anywhere," and: "I am given choices and not forced to do anything."

We saw that people's care needs were assessed and planned for with any risks associated with their care being minimised as far as possible.

People told us that they could do what they wished and were given choices in their daily lives.

People had the equipment they needed to support their care needs and keep them safe. Equipment was monitored and maintained.

Staff said that they were well supported and had opportunities for training. We saw that staff were trained in essential areas such as moving and handling. Staff had also received training in dementia care to help ensure good and consistent practice.

People spoken with thought that the staff knew what they were doing and were generally available to them when they needed assistance. We did find that staffing levels needed to be reviewed to ensure that people always received a timely response when they needed assistance, particularly during the night.

We found that people felt able to raise complaints or concerns about any aspect of the service. People's complaints were looked into and resolved where possible.

People told us that they were happy living in Elizabeth House. People said that the staff were kind to them, and that they were happy with the care and support they received.

People said that they enjoyed good food, were offered choices and lived in pleasant surroundings. People appreciated having their own rooms and liked being able to have their personal items around them to reflect their own interests and families.

Relatives spoken with were happy with the service. One person said, “They are very nice people. Any concerns we have had they have addressed."

People told us that they liked living at Elizabeth House. They were happy with the food and felt that the staff team were kind and friendly. People said that they had choice in their day to day lives and that they were treated respectfully.