We completed an unannounced inspection of Elms House on the 19 September 2018 and returned on the 12 October 2018 to confirm some information. This was the first inspection of this location since a change of provider.

Elms House is a care home located in Shrewsbury and can accommodate 14 people. 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.

Elms House is registered with CQC to provide rehabilitation and recovery support for younger adults and adults with mental health needs. Elms House consists of 11 bedrooms in a main house and three attached flats. Within the main building people have access to communal lounges, quiet spaces and activity rooms which includes a dedicated relaxation room. At the time of inspection there were 12 people residing at Elms House.

Elms House is required to have a registered manager in post. At the time of inspection, the home did not have a registered manager in post however a new manager had been appointed and a start date identified. 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 this inspection we found that Elms House was in breach 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 the report.

We identified that following a Fire Risk Assessment completed in 2017 actions were requested of the provider. Unfortunately, Elms House could not evidence that appropriate action had been taken. We found that people did not all have a Personal Emergency Evacuation Plans (PEEP) and that required works to the property remained outstanding.

We found that some actions from health and safety audits had not been addressed in a timely manner.

We found that medicine was not always being safely managed as the procedures for people taking medicine home was not included in the provider’s policy and that there was inconsistent practice in the team. We also found that protocols for ‘as and when’ required medicine, needed further details.

Elms House was a clean and homely building but on the day of inspection it was noted cleaning products had been left unattended, which left people at risk. When we spoke with the management team we were made aware that they had made the same observation and immediately addressed this issue.

People were safeguarded from abuse and staff had a clear understanding of their role in reporting any concerns.

We found that there was sufficient safely recruited staff to meet people’s needs. Staff were trained in subjects such as safeguarding, first aid, food hygiene. We found that staff had knowledge of mental health conditions and disorders such as Autism but that there had been a lack of formal training on such subjects.

People were treated with kindness and respect. People were involved in decisions about their care. People felt listened to and they knew how to raise a complaint if needed.

People received care and support that was relevant to their needs. Detailed risk assessments were completed and people were actively encouraged to become more independent. People had access to a wide range of activities.

People were supported by the wider multi-disciplinary team and supported to make plans for the future.

Elms House does not provide end of life care and there was no one at Elms House requiring this type of support.

Notifications to CQC were submitted as required.