This inspection took place on 18 October 2018, and was unannounced. At the last inspection completed on 20 December 2017, we rated the service as Requires Improvement.

At this inspection we found that whilst some improvements had been made more were needed and the provider was not meeting the regulations for safe care and treatment and governance arrangements. You can see what action we asked the provider to take at the end of this report.

Elizabeth House is a ‘care home’. 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 can accommodate up to 35 people in one adapted building. At the time of the inspection there were 28 people using the service.

There was a not a registered manager in post at the time of our inspection. The provider had a manager in post and they had plans in place to make an application to register. 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 provider of the service had changed since the last inspection. The new provider had began a program of change to address the issues identified in the last inspection report and make quality improvements to the service.

Governance systems were not consistent in identifying concerns or driving improvements. Medicines were not always administered as prescribed. Staff were not consistently available to engage with people.

Staff had been safely recruited, however improvements were needed to documentation which supported this.

Risks to people were assessed and planned for, however they sometimes lacked detail. People received support from staff that were caring. However, improvements were needed to make sure that this was consistent.

Accidents were investigated and learning was in place to prevent further occurrences. People were protected from the risk of cross infection as staff were observed using effective infection prevention practices.

Staff received training and their competency was checked. Staff felt supported in their role and people received consistent support. Improvements had been made to the environment to ensure this was suitable for people and more were planned.

People were supported to have maximum choice and control of their lives and staff were aware of how to support them in the least restrictive way possible; the policies and systems in the service were supportive of this practice.

People’s communication needs were planned. People not consistently spoken about with dignity.

People’s preferences were clearly documented and staff understood these. People had access to activities. People had discussed their end of life wishes and these were documented in their care plans. People understood how to make a complaint.

People felt safe and were safeguarded from potential abuse. People were supported to eat and drink safely. People were supported to maintain their health and well-being.

Notifications were submitted as required and the manager understood their responsibilities.

We found people were engaged in checking the quality of the service.

The location has previously been rated as Requires Improvement. At this inspection the provider had not made all the required improvements. We may consider enforcement action if there is a continued lack of improvement at our next inspection.

This inspection took place on 20 December 2017 and was unannounced. At the last inspection completed on 28 September 2016 we rated the service as requires improvement. We found the provider was not meeting all the requirements of the law. The provider had not assessed people's capacity to consent to their care in line with the Mental Capacity Act (2005) to ensure that decisions were made in their best interest. We asked the provider to submit an action plan outlining how they would make the necessary improvements. During this inspection we found improvements had been made and the provider was meeting the regulations. However there were other areas which required improvement found during this inspection. You can read about these in the report.

Elizabeth House is a ‘care home’. 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 can accommodate 35 people in one adapted building. At the time of the inspection there were 32 people living in the care home.

There was a registered manager in post at the time of the 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 2008 and associated Regulations about how the service is run.

People were not always supported by sufficient staff and this meant they had to wait for their support. Staff were recruited safely. People were protected from harm and they had risks to them assessed and managed appropriately. Medicines were managed safely and people had them administered as prescribed. Premises were safely maintained and staff understood how to prevent the spread of infection. The registered manager analysed incidents to help them learn when things went wrong.

Improvements were required to the environment, some decoration required updating and consideration of how the environment needed to be to support people with specific needs. We made a recommendation about creating an environment to support people living with dementia. Staff were trained to deliver effective support to people and had their competency checked. 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 access to a choice of meals and were supported to meet their needs and preferences for food. Health care professionals were involved in people’s care and there were systems in place to ensure the care people received was consistent.

The staff were kind and caring in their approach, however they were not always able to provide a caring service to people due to insufficient numbers of staff being available. People make decisions and choices and were supported to maintain their privacy and dignity. Relatives were encouraged to visit and made welcome by staff.

People’s needs were assessed and they received personalised care and support. People understood how to make a complaint and were confident these would be addressed.

The systems in place to monitor the quality of the service were not always effective. A registered manager was in post and was freely available to people, relatives and staff. People and their relatives found the registered manager was approachable. Staff were supported to provide consistent care and support.

We inspected Elizabeth House on the 28 September 2016 and it was unannounced. It provides accommodation and personal care for up to 35 people, some of whom are living with dementia. There were 32 people living at the home when we visited. Elizabeth House was last inspected on 4 June 2014 and was compliant against the standards we looked at.

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 was also a manager who supported staff on a daily basis and they had made an application to become the new registered manager. We will refer to them as the manager within this report.

Assessments were not always completed to ensure that people were able to make decisions about their care and support. Some decisions had not been reviewed to ensure that they were in the person’s best interests and some restrictions on people were not legally approved. Staff were not always able to demonstrate how the training that they attended enabled them to support people effectively.

The provider was reviewing their procedures and quality systems and was in the process of implementing new ones. Some of them were not fully embedded to drive improvements to the service and not all of the staff team were aware of the changes or how they affected them.

Risk to people’s health and well-being were assessed and managed to ensure that people were safe. Staff were able to recognise signs of abuse and knew how to raise any concerns. People were supported to have enough to eat and drink and specialist diets were catered for. The provider worked closely with healthcare professionals to ensure that people’s health needs were met in a timely manner. Medicines were administered to meet individual needs and were stored securely. There were systems in place to ensure that the risks associated with them were reduced.

People told us that there were always enough staff to meet their needs promptly and that they felt safe. Their care plans were regularly reviewed to correspond with changing support needs. Staff developed caring relationships with the people they supported which were respectful and patient. They knew people well and provided care that met their preferences and respected their privacy and dignity.

People were encouraged to pursue interests and hobbies and regular activities were planned. Celebrations were organised for special events and visitors were welcomed at any time. People knew the manager and any complaints or feedback were responded to and learnt from.

You can see what action we told the provider to take at the back of the full version of the report.

We carried out an unannounced inspection on 4 June 2014. Our inspection was part of the annual cycle of inspections. We also reviewed the arrangements for people’s bedroom door locks in response to concerning information we had received. We talked with the provider/registered manager and the staff. We reviewed information given to us by the provider. We met and spent time with eight people who lived at Elizabeth House and three relatives. We looked at the areas of concerns which we had been made aware.

We considered our inspection findings in relation to the following area of the service provision:

Is the service safe?

From our observations and from the information we saw set out in care plans, policies, procedures and audits the provider's safety monitoring systems were robust. The staff showed that they had a clear understanding of their role in providing care and safeguarding the people they supported. The staff demonstrated that they knew the people well and had read and understood the instructions set out in individual care plans.

We saw evidence that people were supported to make decisions and maintain their independence. The care plans set out detailed information for staff of each person’s capacity to consent. When people lacked the capacity to make important decisions, meetings were held to make decisions for them that were in their best interests.

We saw that everyone was encouraged to eat a healthy balance diet. Where people needed support at meal times this was provided. The staff received regular training in nutrition and food hygiene.

From our observations and from the information we saw set out in policies, procedures and audits the provider's hygiene monitoring systems were robust.

The staff rotas showed that the management had taken people's care needs into account when making decisions about the number of staff required, the skills mix and experience staff would need. The rotas showed where necessary additional staff hours were being introduced. The night time staffing levels and on call system showed that the staffing provision was safe out of main hours.

We found no evidence to support the concern that locks could be set so that people were confined to their rooms at night.

There were systems in place to make sure that management and staff learned from events such as accidents and incidents, complaints, concerns and investigations. This meant that people were benefiting from a service that was taking on board lessons learnt.

Is the service effective?

People's health and care needs had been assessed and detailed care plans were in place. There was evidence of people and their representatives being involved in assessments of their needs and planning their care.

We saw that Specialist health and social care professionals regularly gave support to the service. All care, activity and risk assessment plans were reviewed regularly. Every person had a representative and advocacy services were available if required.

We saw that the people who lived at Elizabeth House were supported to maintain their mobility and independence.

The provider/registered manager told us that there were no deprivations of liberty safeguards in place for the people who used the service. They said that in the light of new guidance they were in the process of reviewing the requirements.

Is the service caring?

We observed during our visit and saw in people's care plans that people were supported and encouraged to live full and active lives. People took part in a wide range of leisure and social activities. We saw evidence in care plans, from talking to relatives and through observation that the care provided was being constantly adapted to meet people’s needs.

The people we spoke with who used the service told us they were very comfortable there. They said care and support they received was very good. One person said, "The staff are really caring." Another person said, "I can't fault it. Everyone looks after me and I have no complaints at all." Families we spoke with said their first impressions had been born out with the excellent care which was provided.

Staff showed people respect and maintain people's dignity at all times. We found no evidence to support the concern that locks could be set so that people were confined to their rooms at night.

The staff we spoke with demonstrated that they were committed to providing the best levels of care for the people who used the service. They demonstrated to they were aware of potential risks, people's rights and their responsibilities.

Is the service responsive?

We found that care plans were person centred and contained detailed information about people's choice and preferences. We saw that people’s health and support plans were regularly up dated to reflect people’s changing needs.

There was regular support from external social care and health professionals when needed this meant that people's health and social care needs were being monitored and addressed.

The families and people who lived at Elizabeth house said that if they had any concerns about anything they could talk with the manager or the staff as they were always there and addressed anything they raised.

We reviewed the accident/incident audits and the notes from staff and residents meetings and noted that any issues raised issues were taken seriously and action taken to resolve them.

We were told about and we saw that staff received regular training to meet the support needs of the people who used the service.

Is the service well-led?

Elizabeth House has had stable staff team for some years and there was a clear management structure. The provider/registered manager was knowledgeable about, the people and staff. They were able to tell us how they maintained their learning through appropriate professional bodies and information received.

The people we spoke with used the service and the staff said that the provider/registered manager was always around to give advice and support. Records seen by us showed that any identified shortfall were addressed. There were systems in place to provide feedback to staff about changes and developments.

We saw that the management had held discussions with people who used the service and staff relating to concerns people had about abuse or neglect in light of the recent national reports. All the staff we spoke with said that if they witnessed poor practice they would report their concerns.

Staff we spoke with told us that they had worked with the people who lived at the home for some time and really enjoyed their work. They told us that there was a good team spirit and everyone listened to any concerns raised and acted to resolve these. They said that they felt they were supported and involved in the development of the service.

During this unannounced inspection we spoke with eight people who used the service and two sets of visitors. We spoke with most of the staff on duty and spoke in detail to the provider/registered manager and assistant manager.

The people who used this service told us they were happy with the care and support they received. One person said, "The care is excellent here." Another person said, "I can't fault it. I have no complaints at all."

Since our last inspection on 3 January 2013 the provider had made the necessary improvements to the management of medication ensuring that this was stored and audited more safely and effectively.

The visitors we spoke with were also very complimentary about the services provided to their relatives. A person said, "The owner goes out of his way to ensure that everything is right and nothing is too much trouble. All the staff are lovely here."

We observed staff to be attentive to the needs of people and saw that care and support was delivered according to people's individual needs and to how each person prefered it.

The manager and staff communicated well with people who used the service, including people with reduced mental capacity, ensuring that people were involved in their care.

People were cared for by a skilled staff team and the provider supported staff to maintain their professional development.

The provider maintained a programme of quality monitoring, ensuring that people received effective quality care.

Thirty three people were in residence when we undertook our inspection. We spoke with seven people living in the home, three visitors, three staff and the registered manager. The inspection was unannounced which meant the provider and the staff did not know we were coming.

People's privacy and dignity were respected. We saw staff knocking on people's doors and waiting for an answer before entering. People using the service were happy living at the home. They told us they enjoyed their lives there and they liked the staff who cared for them. One person said, “They are very good here, I couldn’t wish for better carers, they have time for you.”

The staff knew about the people they were caring for, and they felt that the management of the home was supportive and encouraging. One staff member told us, “Support is always on hand. You can talk to the senior staff and the manager and they will always listen.”

We looked at the way medication was managed and saw that improvements were needed to ensure medication systems and practices were safe and suitable.

We looked at the recruitment procedures for staff and found that appropriate systems were in place to protect people using the service.

We checked records were stored safely and correctly. In the main systems were as required, where record keeping storage required improvement we were informed by the registered manager it would be done on the day of our inspection.