This inspection took place on 20 November 2018 and was unannounced.

Elizabeth House Residential Care Home provides a service for up to 14 people in Mansfield Woodhouse Nottinghamshire, who have needs associated with ageing or are living with dementia. On the day of our inspection eight people were living at the service.

The service had 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

At our last inspection on 10 November 2016 we rated the service ‘Requires Improvement’. Shortfalls in the fundamental care standards were identified in how people received their medicines, the cleanliness of the service, the choice of activities available and the systems in place to monitor quality and safety. At this inspection, we found ongoing concerns and some new shortfalls in the care and support people received. We also took account of the inspection history; the service had continued to not reach the minimum fundamental care standards people should expect.

Staffing levels and deployment of staff meant people did not consistently receive quality care. Staff had to multi-task and had limited time to spend with people, this compromised how people received care and support. Safe staff recruitment checks were completed before staff commenced their employment.

The management of medicines did not consistently follow best practice guidance. Hand written entries on medicine administration records did not always have two staff signatures, to ensure information recorded was accurate. Topical creams did not routinely have the date recorded of when they were opened and some prescribed creams were left in a communal area.

The recommendations made by the local commissioning group infection control audit in 2017 and 2018 had not been fully complied with.

There was no analysis of accidents and incidents to consider themes and patterns. Staff were aware of risks associated with people’s needs, but these were not consistently recorded and may have impacted on people receiving inconsistent care and support.

Safeguarding procedures were in place to protect people from abuse and avoidable harm and discrimination. Staff received refresher training and opportunities to discuss their work and development needs.

People received a choice of meals. Where a pureed diet was required, there was no consideration in how this was presented. Staff were aware of people’s needs but information available for staff was not consistently up to date. People were supported with any health conditions

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. Staff were aware of the principles of the Mental Capacity Act 2005.

Staff were kind and caring, but people did not consistently experience dignity and respect in how their needs were met because staff were over stretched and task focused. People were seen to not have a positive lunchtime experience. Staff were seen to assist people with their eating needs standing up and were frequently interrupted to assist other people.

The social activities, stimulation and opportunities for people continued to be limited. The activity plan on display did not match the activities available. We have made a recommendation about the social activities and opportunities available for people.

People had access to the complaint procedure. Advocacy information leaflets available for people were out of date. Considerations of people’s end of life care had been discussed with them.

As part of the provider’s quality assurance process, people and their relatives received an opportunity to s

This inspection took place on 10 November 2016 and was unannounced.

Elizabeth House Residential Care Home provides a service for up to 16 men or women who have needs associated with ageing or a dementia type illnesses and is situated in Mansfield Woodhouse Nottinghamshire. On the day of our inspection 11 people were using the service.

The service had 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

There were enough staff with the right skills and experience to meet people’s immediate needs. We found that medicines were stored correctly, however they were not always administered safely. People’s care records showed that any risk to their safety had been identified and measures were put in place to reduce these risks, but the cleaning schedule in place had not identified debris behind the tumble drier which could have presented a hazard. People who used the service and staff at Elizabeth House knew who to report any concerns to if they felt anything untoward had occurred.

People were supported by staff who had received the training they needed to support people effectively. People had consented to the care that they received. People’s rights were protected because staff acted in accordance with the Mental Capacity Act 2005. The principles of the Deprivation of Liberty Safeguards were understood and applied correctly.

People spoke positively about the food they received. They were able to have choice in what they ate at each meal and received support to eat if required. People had regular access to their GP and also other health care professionals when required.

People were supported by staff who were caring and treated them with kindness, respect and dignity. Staff encouraged people to remain independent wherever possible and where people showed signs of distress or discomfort, staff responded to them quickly. There were no restrictions on friends and relatives visiting their family members.

A complaints procedure was in place and people felt comfortable in making a complaint if needed. People received the care they needed in a way that met their needs. We saw staff provide planned care well. While a range of group activities were planned none were taking place on the day of our inspection. Care plans were written with the involvement of each person and their family. They were reviewed regularly to ensure staff responded appropriately to any change in need a person may have.

Processes were in place to check on the quality of the service, but there was no overall action plan to demonstrate improvement. The atmosphere within the home was warm and friendly. People living in the home were asked for their opinions with regard to the service that they received. Staff understood the values and aims of the service and spoke highly of the registered manager, who had a good understanding of their regulatory responsibilities.

This inspection took place on 14 January 2015. Elizabeth House Residential Care Home provides residential care for up to 16 older people, including people with dementia. On the day of our inspection 11 people were using the service.

The service had a registered manager at the time of our inspection. 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.

When we last inspected Elizabeth House Residential Care Home in July 2014 we found there were improvements needed in relation to how people gave consent to their care and treatment, care and welfare, safeguarding, supporting staff and assessing and monitoring the quality of the service. The provider sent us an action plan telling us they would make these improvements by January 2015. We found at this latest inspection that the provider had made some improvements in line with their action plan for safeguarding and supporting staff. However there were still improvements needed in relation to getting people’s consent to care, care planning and how the quality of the service was being monitored.

Staff knew how to keep people safe and to raise any concerns if they suspected someone was at risk of harm or abuse. Staff understood the risks people could face through everyday living and how they needed to ensure their safety.

The staffing arrangements did not ensure there were sufficient staff on duty to meet people’s needs.

People received their medicines as directed and these were administered in a sensitive manner. However they were not always stored as safely as they should be to keep them at their most effective.

People were not always protected under the Mental Capacity Act 2005 (MCA) which is in designed to protect people who lack capacity to make certain decisions because of illness or disability.

Staff received training and supervision so they knew how to provide people with safe and appropriate care.

People were encouraged to eat and drink well, and were supported with their healthcare needs. We observed people were treated with dignity and respect. People felt staff were kind and respectful to them.

People’s care plans did not provide staff with the information they needed to support people appropriately and the service people received was not adequately monitored.

Prior to our visit we reviewed all the information we had received from the provider. During the visit we spoke with five of the 11 people who were using the service, two relatives and a visiting doctor and asked them for their views. We also spoke with three care workers and the registered manager. We looked at some of the records held in the service including the care files for five people. We observed the support people who used the service received from staff and carried out a brief tour of the building.

We carried out this inspection to answer five key questions; is the service safe, effective, caring, responsive and well-led. Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We found people’s care and support was not planned and delivered in a way that ensured their safety and welfare. Staff told us that one person had needed to explain to staff how to carry out a procedure as the information in the care file did not explain how to do so.

A visiting doctor told us they felt people who used the service were safe at the home. A person who used the service said, “I feel very safe here.” However staff did not know how to respond to any allegation of abuse. Staff told us they had not done any safeguarding training and were unclear about what whistleblowing was.

Staff on duty who administered medication had not completed the training required to do so safely.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. The manager told us they understood when an application should be made, and how to submit one.

Is the service effective?

The provider was unable to demonstrate how they involved people in planning their care, and obtaining people’s consent for this to be provided.

We found mental capacity assessments had not been completed correctly. Staff did not understand the principles of the Mental Capacity Act (2005) and had not received training on this.

Care plans did not always contain details of the care and support people needed. One care plan referred to a person going to a local church. A staff member said, “I don’t know anything about that, I don’t read the care plans.”

Staff were keen to respond to people’s needs and requests, however we observed occasions when this could have been done more effectively. We saw three staff tell one person how they would support them after lunch differently, which could have confused the person.

The majority of entries on the activity records consisted of things along the lines of, “Relaxing in lounge”, “Listening to music” and “Watching television.” We asked a person who used the service if there was much for them to do. The person said, “No, I am happy here, but they could organise more for us to do.”

Is the service caring?

We found staff interacted with people who used the service in a sensitive and caring manner. We observed staff to be attentive, caring and well intentioned. A person who used the service said, “We get individual attention.” Another person said, “They help me, they are very good.”

We saw people were provided with the assistance they needed to eat their meals. A person who used the service said, “I can’t fault the meals, they are very nice.”

Is the service responsive?

We found care workers responded appropriately when people had the capacity to make decisions about their care and welfare. A person who used the service said, “I think staff listen to me.”

People who used the service were happy with their health care. One person said, “The doctor comes to see us regularly when we need it.”

We found the provider responded to the views of people who used the service. A person told us the manager was, “Easy to talk to.” We also heard a person say to the manager, “I am being looked after very well.”

Is the service well-led?

There were not management structures and procedures in place to ensure staff received the support and supervision they needed to carry out their duties. Staff described their induction as, “Brief.” A person who used the service said, “They are trained, they don’t just employ anyone, they are vetted first.”

A person who used the service said, “The staff are very nice, I trust them with anything.” However we found the staff training matrix and supervision records were not up to date.

The manager told us they did not carry out routine audits within the home as they tended to deal with things at the time. This meant they did not make use of opportunities to identify and improve the service. We also found there was a lack of planning for the maintenance and upkeep of the home.

This inspection was carried out to follow up on our previous inspection in August 2013, where we found the provider was not compliant with one outcome.

Prior to our visit we reviewed all the information we had received from the provider, including an action plan detailing how they would comply with the compliance action we set at the previous inspection. During the visit we spoke with the registered manager, a senior care worker and a care worker. We also did a tour of the communal bathrooms and toilets and looked at the cleaning schedules.

We found the provider had made the required improvements to become compliant with this outcome.

Prior to our inspection we reviewed all the information we had received from the provider. We spoke with three people who used the service, three relatives and a visiting professional for their views. We also spoke with the registered manager, the cook and two carers. We looked at service information, care plan files for three people and did a tour of the building.

People who used the service told us they were happy and settled, and that they felt they were well cared for and supported. Comments included, “I get up at the time I choose. They (staff) are always obliging and help me when I request support.” And, “I’m happy here; I’m settling in well and getting to know people.”

Relative’s comments included, “This home is better than the last one my mum was in.” And, “If I had to mark the home out of 10, I would give it 11. They (staff) not only look after my husband but support me too.”

A visiting professional told us, “The staff are helpful and polite, I get good feedback from my patients that live here. It’s a nice relaxed atmosphere, people are well looked after.”

People who used the service and relatives told us they found staff to be caring, experienced and competent. A relative told us, “I wanted my dad to come here, he couldn’t be better looked after.”

We saw improvements had been made to the cleanliness of the home but we found further work was still required.

Prior to our visit we reviewed all the information we had received from the provider.

As part of our inspection we spoke with three people who used the service and two relatives of people who used the service. We also spoke with the registered manager, two members of staff, looked at service information and records and did a tour of the building.

People told us they were treated with dignity and respect and their care needs were well met. One person told us, “I’m happy living here, I feel content. The girls (staff) are very caring.”

Another person said, “There are enough staff for the people here at the moment. The food is lovely and you get a choice.”

Relatives we spoke with were positive about the care provided. One relative told us, “It’s lovely here, the staff are caring, as good as gold. I’m always made welcome when I visit, I can’t find no fault.”

Another relative said, “We were involved in my father's assessment, we have signed care plans and had a meeting with the manager whilst my father has been here. This home was recommended to us, my father was apprehensive at first but after a short time said, “This is the place for me”, and you can’t get any better than that.”

We found care plans did not always reflect people’s needs and there were some concerns with the lack of infection control measures in place.

We spoke with three people who live at Elizabeth House, and asked them for their opinion of the care that they are receiving. All three said that they were very happy at the care home, and made the following specific comments: “Yes, I do like it here, the girls (staff) are very nice, and I’ve got nothing to complain about.” “It’s alright, we are well looked after.” “The staff are kind.” “I’m very happy here.”

We also spoke with one relative who made the following comments: “The staff are friendly and helpful, and they keep me informed.” “The care is very good, they look after people well, the food is very good, and there are no issues.”

People were asked if they felt safe, or had any concerns about the care they were receiving. In each case the person said they felt safe, and twice the term: “very safe” was used. In addition we spoke to a relative, who told us that he visited regularly, and had never seen anything to cause him concern, and that if he did not feel his father was safe at the home he would make arrangements to move him elsewhere, but this was not the case.

We spoke with people regarding the staff, and staffing levels. All three said that they thought there were enough staff to meet their needs. Observations during the inspection did not raise any concerns about staffing levels, and discussions with three staff members showed people who were knowledgeable about their roles and responsibilities within the care home.

Discussions showed that the manager/ provider had daily contact, and that people are able to talk about any issues. The relative who we spoke with also said that if he had any problems or issues he was able to go straight to the manager/ provider to raise them. None of the people spoken with thought that there was any problem with regard to communication with the provider of the service.