This inspection took place on 6 December 2018 and was unannounced. The inspection was carried out following significant and ongoing concerns about the safety and effectiveness of people’s care; shared with us by local care commissioners and external health care providers involved in people’s care at the service.

Elm Lodge Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission [CQC] regulates both the premises and the care provided, and both were looked at during this inspection. Single use accommodation and personal care is provided at this service in one adapted building over two floors, for up to 46 older people who may be living with dementia. Both floors of the building provide a dining room and two communal lounges. A secure garden area provided level access for people. At the time of our inspection there were 30 people using the service. All were older adults living with dementia, including many with other chronic health conditions, and some with sensory physical disability needs.

There was no registered manager for the service since November 2018. A registered manager is a person who has registered with the CQC to manage the regulated activities provided at the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements of the Health and Social Care Act (HSCA) 2008 and associated Regulations about how the service is run.

At our previous inspection in January 2018, we rated the service as Requires Improvement for the third consecutive time. People were not always protected from risks associated with unsafe, ineffective or inappropriate care that did not meet with their needs and preferences. The provider also did not operate effective governance systems at the service to consistently ensure the quality and safety of people’s care. These were respective breaches of Regulations 9 and 17 of the HSCA 2008 (Regulated Activities) Regulations 2014. We asked the provider to send us a written report, to tell us what action they were taking to make the improvement required to rectify the breaches and to improve the service to a rating of a least Good. At this inspection we found these improvements were not made.

The provider did not operate effective systems for governance and oversight of the service, or demonstrate lessons learned when required, to ensure the quality and safety of people’s care at the service. Pro-active, sustained and ongoing care and service improvement was not consistently ensured for people’s health and welfare.

The provider did not always tell us or others with an interest in people’s care when things went wrong at the service; or regularly consult with relevant parties help inform or improve people’s care.

Records relating to people’s welfare and the management of the service were not accurately maintained. National guidance was not always followed or reviewed for people’s care.

People who could tell us felt generally safe at the service. People’s safety was not consistently ensured. Risks to people’s safety were not always effectively accounted for, managed or mitigated and people’s medicines were not always safely managed.

There were not always enough staff to provide people’s care and staff were not always safely recruited. The provider’s subsequent improvement actions, which helped to mitigate the risk to people from unsafe staffing arrangements, needed to be demonstrated as continued and sustained.

Staff were trained and generally knew how to recognise and report abuse. Staff and management did not always recognise or act on discriminatory practice, to fully ensure people’s rights, needs and choices in their care.

The service was mostly clean and hygienic but this was not consistently ensured, to fully protect people from the risk of an acquired health infection through cross cont

We inspected this service on 26 January 2017 and the inspection was unannounced. Elm Lodge is registered to accommodate 46 people in one adapted building and support is provided over two floors. Both floors had a dining room and two communal lounges. A secure garden area was available that people could access. At the time of our inspection 41 people were using the service.

The service had 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.

At the previous inspection on the 23 June 2016 the provider was meeting the regulations that we checked but further improvements were needed in the quality of people's care. We rated the safe, responsive and well led domain as requires improvement and the overall rating for the service was Requires Improvement.

At this inspection we found improvements had been made in the safe domain, but improvements in the responsive and well led domain were needed. This is the third consecutive time the service has been rated overall as 'Requires Improvement'. Providers should be aiming to achieve and sustain a rating of 'Good' or 'Outstanding'. Good care is the minimum that people receiving services should expect and deserve to receive and we found the systems in place to ensure improvements were made and sustained were not effective.

The improvements we asked the provider to make at the last inspection, to ensure people were offered a consistent programme of activities that met their needs had not been achieved. We identified that the activities available at the last inspection were reliant on the availability of the activities coordinator. At this inspection the lack of a specific person to provide activities meant that people were receiving fewer activities than they were at our last visit. This was because the provider had not made sufficient alternative arrangements to ensure people were provided with activities on a consistent basis. Although the majority of records looked at were up to date, some were not and didn’t reflect people’s current care needs. This demonstrated that the systems in place to monitor the service and identify where improvements were needed were not effective.

Staff understood their role to protect people from the risk of harm and understood their responsibilities to raise concerns. Individual risks to people and environmental risks were identified and minimised to maintain people’s safety. Assistive technology was in place to support people to keep safe. Systems were in place to prevent and control the risk of infection.

People were protected against the risk of abuse, as checks were made to confirm staff were of good character. There was a sufficient skill mix of staff available to meet people’s care needs. Medicines were managed safely and people were supported as needed to take their medicine as prescribed and access healthcare services.

People were consulted regarding their preferences and interests and the staff team knew people well. People were supported by staff that were trained and they were supported with their dietary needs and to access healthcare services to maintain good health.

People were supported to have maximum choice and control of their lives and staff understood the importance of gaining people’s consent regarding the support they received. The policies and systems in the service supported this practice.

People's rights to privacy and dignity were respected and they were supported to maintain relationships with people that were important to them. People’s representatives were involved the assessment and development of their care plans. There were processes in place for people to raise any complaints and express their views and opin

This inspection was unannounced and took place on 23 June 2016.

Elm Lodge Care Home provides accommodation and personal care for up to 40 older people living with dementia. At the time of our visit, there were 32 people living at the service. There was a registered manager at this service. 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 of the service in July 2015 we found the provider’s arrangements to obtain consent for people’s care, for staffing and cleanliness at the service and for effective governance were not sufficient to ensure that people received safe and effective care. These were respective breaches of Regulations 11, 18, 12 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014. Following that inspection the provider told us about the action they were taking to rectify the breaches. At this inspection, we found that improvements were made were sufficient to rectify the breaches but further improvements were needed in the quality of people’s care.

Significant improvements were made to the provider's arrangements for the management and oversight of the service and to check the quality and safety of people’s care. Additional improvements were planned from this which helped to protect people against the risk of unsafe or ineffective care and treatment. Further improvements were needed in relation to the quality, approach and timeliness of people’s care and to demonstrate the provider’s ability to sustain continuous service improvement.

People, relatives and relevant external authorities had increased confidence in the management of the service. The registered manager told us about important events that happened at the service when required. Staff generally understood their role and responsibilities for people’s care. They knew how and were confident to report any significant incidents or changes relating to people’s health or safety needs. Improvements to ensure a more thorough and consistent approach to staff supervision arrangements were in progress.

Staffing arrangements were mostly sufficient to provide people’s care. However, senior staff did not always have time to supervise staff and monitor people’s care, which meant that people did not always receive timely care and support. The provider’s action to recruit additional senior care and provide additional care staff at busier times of the day, helped to mitigate the risk to people’s safety from insufficient staffing arrangements.

The home was generally kept clean and odour free. Systems improvements had been made for infection control, prevention and cleanliness at the service, but staff did not always follow safe practice to ensure this. Further improvements were identified through the provider’s revised management checks in relation to cleaning records, staff practice and use of personal protective equipment. This helped to protect people from the risk of acquiring a health associated infection.

The service ensured people’s rights and best interests by working within the principles of the Mental Capacity Act (MCA) to obtain people’s consent or appropriate authorisation for their care.

The provider’s safeguarding and staff recruitment procedures helped to protect people from the risk of harm and abuse. Information from visiting professionals and the provider showed that staff did not always follow people’s care plans to support people safely when they provided care. The provider’s action plan to address this with staff helped to protect people from unsafe care.

People’s medicines were safely managed but not consistently recorded. Improvements were identified and planned from the provider’s management checks to e

A single inspector carried out this inspection. We spoke to five people who used the service, two visitors and three members of staff. Below is a summary of what we found. The summary describes what people using the service, their relatives and staff told us, what we observed and the records we looked at. If you want to see evidence that supports our summary please read the full report.

Is the service safe?

People were cared for in an environment that was safe, clean and hygienic. Staff had a good understanding of the needs of people living in the home. They were able to describe people’s individual needs and what care they required. We saw that people’s needs were assessed and care and treatment was planned in line with their individual care plan.

We saw from staff training records that most had received training in safeguarding vulnerable adults. Staff we spoke with knew how to recognise the different types of abuse and how to report any suspicion or the witnessed abuse of any person using the service.

We saw that some people had had assessments for mental capacity and that families were involved in decision making when people did not have capacity.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes to ensure that proper legal processes are in place if a person lacks capacity to make decisions and their liberty is restricted in some way. While no applications had needed to be submitted, proper policies and procedures were in place for this. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service effective?

We spoke with six people who used the service. They told us that they were given choices about how they spent their days. One person said “It’s lovely. I play games. I enjoy living here.” Two other people said, “They look after me well", and “Staff, are all nice; I have my own key to my room and I am able to go out with my family.”

Is the service caring?

Two people we spoke with said they were happy with the care they received. We spoke with three members of staff who gave examples of how they treated people with dignity and respect and involved people in their care. We observed staff speaking with people in a kind and caring manner and found that people were comfortable in the presence of staff. We spoke with two family members who said they were very happy with the care provided. One family member said “She seems very happy here and they look after her well”.

Is the service responsive?

During our visit we looked at five people’s care plan records. Each contained assessments of people’s individual needs. For example, for their mobility, personal care such as hygiene and dressing, nutrition and continence needs. We saw that any risks to people’s safety were determined and care was planned to mitigate any risks that were identified. These included risks from pressure sores, inadequate nutrition and falls. We saw that all risk assessments had been reviewed and were up to date. We saw that healthcare professionals were involved in people’s care and treatment where required.

Is the service well led?

The home carried out a quality assurance survey which was sent to people's families. We saw from the response that families were happy with the care. We saw that audits were carried out across areas such as infection control, medication, food hygiene and care plans. The audits we saw demonstrated that good standards of care were in place.

We found that people who used the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. We saw that the provider and the manager held regular meetings with people and their families.

The purpose of this visit was to check the action taken by the provider, since our last visit in July 2013, to ensure they were meeting essential standards. We did not speak with any people who use the service but gathered evidence of people’s experiences of the service by other means.

From reading people’s care records, we found that, where they were unable to make informed choices about important life decisions their best interests were being fully considered.

We found that attention was given to people’s comfort while being moved in wheel chairs. Also, systems were in place to ensure that people received their own clothes after laundering.

We spoke with one of the people who use the service and with two relatives. They told us that staff respected their privacy and dignity and one person said, “[Staff] knock on my door [before entering]. Very caring here.” People also told us that staff encouraged them to be as independent as possible. One person said, “I can do as I want…I please myself.”

People told us that staff talked things over with them before carrying out their care and asked for their consent before decisions regarding their treatment. However, from reading people’s care records, we found that where people were unable to make informed choices about important life decisions their best interests were not always being fully considered.

The people we spoke with told us that staff respected their personal preferences and they thought that their needs were met. One relative told us, “Staff allow [my relative] to have a lie-in some mornings at [my relative’s] request.” However, people told us that personal clothes went missing. We observed one person being moved in a way that could cause them discomfort.

People told us that the food provided was, “very good”, and we found that, generally, people’s nutritional needs were being met.

People thought that staff were well trained to meet their needs and records confirmed that most staff were up to date with relevant training.

This inspection took place on 1 and 8 July 2015. The inspection was unannounced on 1 July and announced on the 8 July 2015. At our previous inspection in April 2014 we found that the essential standards of quality and safety were met.

Elm Lodge Care Home provides nursing and personal care for up to 40 older adults, most of who are living with dementia. At the time of our visits, there were 31 people were living in the home. There was no registered manager at this service. A new manager had been recently recruited and they intended to apply to become the registered manager at the service. 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’s arrangements did not always ensure that sufficient numbers of suitably qualified, competent, skilled and experienced persons were deployed to meet people’s needs. People, their relatives and staff were not always confident that people received safe care, because they were concerned that staffing levels were not always sufficient to meet people’s needs. Action was being taken to recruit to staff vacancies and by our second inspection visit, the provider had taken some steps to improve their interim staffing arrangements. However, the provider’s interim measures did not always ensure that staffing arrangements were sufficient to meet people’s needs.

The provider’s arrangements for the prevention and control of infection and the cleanliness and hygiene of the premises, did not fully protect people from health risks associated with cross contamination. At our second inspection visit on 8 July 2015, work had commenced to improve some areas of cleanliness and hygiene in the home through recorded checks. However, the checks did not take full account of recognised national guidance for this, which was not always being followed.

The provider’s arrangements did not protect people against the risks of care being provided without appropriate consent or authorisation. Staff had received training, but did not always follow the Mental Capacity Act 2005 when required for people’s care. They did not have all of the guidance they needed to help them to do so. The MCA is a law providing a system of assessment and decision making to protect people who do not have capacity to give consent themselves to their care, or make specific decisions about this.

People’s medicines were being safely managed and people received their medicines when they needed them.

People felt safe in the home and their relatives felt they were generally safe there. Staff, were trained and they were provided with and mostly knew the procedures to follow in the event of their concern about the harm or abuse of any person living at the home. This helped to protect people from the risk of harm and abuse. A few staff did not understand the role of relevant external authorities concerned with protecting people from harm or abuse or how to report any concerns to them to protect people when required. The manager agreed to ensure that all staff had the correct knowledge.

The provider’s arrangements for staff recruitment were robust, which helped to make sure that people were fit to work at the home. Improvements to fire safety arrangements were being made by the provider, through their agreed action plan with the local fire authority.

Overall, staff understood people’s health needs, which were being met in consultation with external health professionals when required. People’s care plans did not always give accurate or up to date information for staff to follow relating to people’s health conditions, how they affected them and their related care needs. This potentially increased the risks to people from receiving ineffective or inappropriate care and treatment. However, improvements were being made to help to make sure that people’s care plans would provide staff with the information they needed to support people to maintain or improve their health.

Staff received most, but not all of the training they needed to provide people’s care. Following our first inspection visit, the provider took appropriate action to address staff training deficits.

People were provided with the support they needed to eat and drink sufficiently. People received a balanced diet, which they often enjoyed, but felt sometimes lacked variety or choice. Menus and records of people’s food preferences, allergies and other dietary requirements were provided, which staff followed. People were also provided with the appropriate consistency of food and drinks, which met with their dietary requirements and the related instructions from relevant health professionals.

Staff, were kind, caring and helpful. They treated people with respect and promoted their privacy, dignity and independence. However, information about people was not always handled respectfully or kept confidentially. Recognised methods that may help to support, involve and inform people living with dementia, about their care at Elm Lodge, were not always fully considered or used to help promote their choice, dignity and independence. We have made a recommendation to the provider to help people living with dementia to stay as independent as they can.

Staff knew people well and people often received personalised care that met their needs. Improvements were being made to develop people’s care plans in a personalised way to better inform staff about people’s individual care requirements. Some improvements were also being made to help re-establish and improve the arrangements for people’s social and occupational engagement to meet with known their preferences and needs.

People and their relatives were supported to maintain their relationships. They were involved in agreeing the care to be provided and its on-going review. People able to express their views and their relatives were comfortable to raise any concerns about people’s care with senior staff. Action had recently been taken to re-establish the provider’s complaints process for the recording and handling of any complaints received about the service. Improvements were planned to regularly seek and obtain people’s views about their care.

The home had not been effectively or consistently managed during 2015. The provider’s checks of the quality and safety of people’s care were not always being followed or acted on to protect people against the risk of inappropriate or unsafe care and treatment. This resulted in their failure to act on areas of concern that we found at this inspection.

However, people and staff were more positive following the recent appointment of a new manager who was visible and approachable. The manager had commenced a working review of some of the provider’s arrangements for the quality and safety of people’s care. They had begun to make agreed improvements in consultation with relevant parties, such as service commissioners and the local fire authority; to help make sure that people received safe and effective care.

We found four 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.