We undertook an unannounced focused inspection of Elroi Manor on 17 May 2018. This inspection was undertaken in response to concerns we had received about the service.

The inspection team inspected the service against two of the five questions we ask about services: is the service well led and effective. No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing 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.

At the last inspection in December 2017 the service was rated good.

Elroi Manor provides a service for up to 26 people. The home is approximately one mile from Wincanton town centre. The home provides personal care for older people living with dementia and other mental health needs. At the time of our inspection there were 20 people living in the home.

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.

Records relating to the repositioning of people who had or were at risk of pressure sores had not always been completed. We did not find any concerns directly about the care of people. However, there was no system in place to ensure staff were providing evidence, through completion of the record, that they had completed the specific care task.

Care planning did not always reflect the complexity of care people needed particularly around pressure care and risk of skin breakdown. There were no specific care plans for skin integrity or assessment to identify people at risk of pressure sores.

Where people had or developed complex health care needs there was no process in place to review their living at the home. This would be to identify where nursing care may be appropriate or what measures were needed to ensure care needs were met. We have made a recommendation about in relation to this this.

People spoke positively about living in the home. One person said, "I have really got on well here it has made a real difference." Another person said, "It feels like home and a family".

People enjoyed the meals provided and one person told us, "The meals are good I always enjoy my meal." Another person said, "I like to sit down and have a meal with people it is a bit of a social occasions."

People's nutritional and dietary needs were met. Where concerns about diet or the need for ensuring people ate well appropriate support was provided.

People described the registered manager as someone who was approachable and always available. Staff also described the registered manager as "Someone we can always go to, she knows what is going and how people are."

The registered manager had responded to our inspection by taking action to address the failures we found around completion of records. They had also put in place improved assessment of people at risk of pressure sores.

The service had worked hard to develop positive relationships with health professionals who regularly visited the home to support people who required nursing care such as pressure sore care.

This inspection took place on 17 December 2016 and was unannounced. It was carried out by two inspectors. Elroi Manor had closed for a period of time and re-opened in February 2016 with conditions on its registration. There was a condition in place that it can accommodate a maximum of 18 service users at the location and another that it must not accommodate service users in a closed of section of the service which has a further 16 bedrooms. The conditions were put into place by CQC and were both being met at this inspection.

Elroi Manor currently provides accommodation and personal care for up to 18 people. There were three vacancies at the time of inspection. The service is located in Wincanton and is a detached single storey building. There is a large communal lounge and separate dining room and people have access to a covered patio space and open gardens. At the time of inspection, the service was not providing nursing care for anyone living at the home.

The service did not have a registered manager at the time of 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. The manager at the home had moved into the post a few months previously and was in the process of applying to register with CQC.

Medicines were stored safely and given as prescribed. We saw that one medicine which required additional checks had an error when it was recorded. There were audits in place to ensure that this did not reoccur.

People were supported by enough, safely recruited staff to meet their needs. Staff were aware of the risks people faced and their role in reducing these risks. Where staff had required training or updates, these had been provided and staff had the necessary knowledge and skills to support people.

People were supported by staff who understood their role in protecting adults from abuse and were able to tell us about the signs of abuse. Staff received training in protecting adults and were confident to report any concerns or to whistle blow if this was required. Staff also received supervision from the manager and were able to discuss any concerns, practice issues or development opportunities.

People were supported to make choices about all aspects of their daily life. This included what they wanted to eat and drink, what activities they were involved in and how they wanted to be supported. Staff understood peoples individual likes and dislikes and how they preferred to receive their support.

Staff sought consent from people before providing support and they were aware of the principles of the Mental Capacity Act and had received training in this area.

Staff were kind and caring and we observed that people were relaxed and had a clear rapport with staff. Staff were familiar to people and supported people in a way which was respectful. Relatives and people were involved in planning and agreeing what support people received and felt that staff knew people well.

People had access to healthcare services when required and we saw that the service had referred to a range of different health professionals to ensure that they were supporting people effectively.

People were supported to have enough to eat and drink by staff who understood what support they

required. People had choices about what they ate and drank and mealtimes were a relaxed, social occasion.

People had individualised care plans which reflected what support they needed and how they wished to receive their support. The service was in the process of transferring care plans to use a more holistic approach. Where these were in place we saw that they were personalised and provided a clear picture of the experience of the person receiving support.

Relatives felt include

The provider was compliant with this outcome at our last inspection. We carried out this inspection to check the number of useable bedrooms and communal areas as it is the intention of the provider to increase the number of people who live at the home. The provider was compliant with this outcome at our last

At this inspection eight of the forty three beds were occupied. As seen at the previous inspection, one part of the home was closed off and was not accessible to people. We viewed all parts of the home. In the part of the home being utilised, accommodation was provided at ground floor level and we found there were 18 bedrooms which could be utilised.

The standard of décor in all but three of these bedrooms was good. The three bedrooms which required attention were not currently occupied The manager informed us these three rooms would be decorated before they were used and there were plans to lay new carpet in two of the bedrooms.

The eight bedrooms being occupied had been furnished in accordance with each person’s tastes and preferences. Five of these bedrooms had en-suite toilets and three had the provision of a sink. The standard of décor and cleanliness in the part of the home currently being utilised was good. People had access to a large communal lounge and dining room, toilets and bathrooms.There were large and pleasant gardens and a covered outside seating area.

The manager escorted us around the part of the home which was closed off. This was accessed through a locked door. This part of the home was not accessible to people who lived at the home. This accommodation was set out over two floors. The manager told us there were plans to re-develop this area and they had ‘no intention’ of using that part of the home until major works had been completed. This was positive as, in its current state of décor and repair; it would not provide a safe, appropriate or homely environment for people.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

This is a summary of what we found:

Is the service safe?

At our previous inspection on 19 November 2013 and 20 November 2013 we found there were not enough qualified, skilled and experienced staff to meet people's needs. This placed people at significant risk of harm. We judged that this had a major impact on people who used the service and served a warning notice. At our last inspection on 7 and 11 February 2014, we found the provider had not taken appropriate action to address this non-compliance.

At the time of this inspection only eight of the 43 beds at the home were occupied. We found the eight people were receiving safe and appropriate care in accordance with their assessed needs. We arrived for this inspection at six thirty in the morning so that we could meet with night staff and check whether people were safe. We found night cover was sufficient to meet the needs and numbers of the people currently at the home. This was confirmed by the two night care staff we spoke with. They told us that nights were covered by two carers and a registered nurse.

By speaking with the manager, members of staff and examining the duty rotas, we saw that staffing levels during the day were in excess of the numbers assessed as being required. The assessment tool calculated the staffing hours required each day as 45. We saw the home were currently providing 84 staffing hours over a 24 hour period. Domestic, administrative and maintenance staff were also employed.

Following our last inspection arrangements had been put in place to deal with foreseeable emergencies. A ‘personal emergency evacuation plan’ (PEEP) had been completed for each person who lived at the home. These provided information about people which included their level of mobility and equipment required. This helped to reduce risks to people in the event of an emergency. A fire risk assessment had been completed in March of this year and we saw that work had commenced on addressing concerns raised by the fire authority. This included replacing the hinges on fire doors.

We observed staff assisting people to transfer to/from wheelchairs with the aid of a hoist. We saw people were assisted in a safe and dignified manner. Staff took time to explain what they were going to do and offered constant reassurance to the people they were assisting. People appeared relaxed and comfortable when being assisted.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. While no applications have needed to be submitted, policies and procedures were in place. Relevant staff had been trained to understand when an application should be made and how to submit one.

Care and treatment was planned and delivered in a way that ensured people’s safety and welfare. Care plans included a range of individual risk assessments and agreed actions for managing these risks. These included reducing the risk of falls, skin damage and malnutrition.

Is the service effective?

We found the service to be effective because people's care treatment and support achieved good outcomes for the eight people living at the home. We also found that people's rights and choices were respected by staff.

We saw staff recorded information about each person on a daily basis. Information included how people had spent their day and how they had responded to activities of daily living. This meant the effectiveness of people’s care plans could be fully reviewed.

Is the service caring?

The staff we spoke with had a very good understanding about the needs and preferences of the people they supported. They understood and responded to people’s needs and requests where individuals were unable to make their wishes known verbally.

Staff interacted with people in a gentle and kind manner. We spoke with two visitors who told us “The care here is very good. The carers are excellent and so kind.”

Is the service responsive?

We read that one person had recurrent urinary tract infections (UTI). At our last inspection we found the management of this condition to be poor. Improvements were noted at this inspection. Care records contained an assessment which stated the individual was at high risk of developing a UTI. The care plan we read detailed how to minimise any risks. We saw that staff monitored the person’s fluid intake in accordance with the plan of care. We observed that staff offered the person regular fluids throughout the day. Care records showed that where the individual had been treated for a UTI, staff had tested a urine specimen to monitor the effectiveness of the treatment.

At our last inspection we found that people were not offered opportunities for social stimulation. We also found people were not sufficiently encouraged to mobilise. At this inspection we found improvements had been made for the eight people using the service. A varied activity programme had been displayed. On the day we visited people were able to have their hair done by a visiting hairdresser. During the afternoon there was a music session. We saw staff were available to respond to any requests by people.

Is the service well led?

At our previous inspections we identified concerns which resulted in us taking enforcement action against the provider. We found the provider did not have an effective system to regularly assess and monitor the quality of service that people received. There were no effective systems in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others.

Following our last inspection the provider/registered manager had commissioned an independent care consultant to review the home’s policies and procedures and the quality of care people received. The provider had also recently employed a new manager. The care consultant developed an action plan which covered the areas of non-compliance found at our last inspection. We were sent weekly reports which detailed the actions taken to address the identified areas which required improvement. A registered manager from a sister home also provided management support to the home. A manager was recently employed and we were informed it was their intention to apply for registration with us.

At this inspection we saw that systems to monitor the quality of the service provided and minimise and mange risks to people in the home had been introduced. However we were unable to assess the effectiveness of these systems as some had only recently been implemented or were in the process of being implemented.

At our previous inspection we identified concerns about the standard of the environment. This related to part of the home which is not currently being utilised as occupancy levels have reduced to only eight people. We were shown around the part of the home which is not currently being used. We saw that this would require significant attention and improvement before it could be utilised. The provider and manager told and assured us that they would not accommodate people in that part of the home until major works had been completed. However, the maintenance schedule we were shown did not include any planned work for this area.

The part of the home currently being utilised provided all accommodation at ground floor level. People had access to a large, light lounge and dining area. We viewed the eight bedrooms being occupied. Each provided spacious accommodation and had been furnished in accordance with each person’s tastes and preferences. The standard of décor and cleanliness in the part of the home currently being utilised was good.

People we spoke with at the home were very complimentary about the meals they had. One person we spoke with commented after her lunch "it was very nice, I enjoyed it". We observed there were sufficient staff on duty to ensure no one had to wait too long for their meals. People's care records demonstrated a comprehensive assessment of people's nutritional needs. Since our last inspection the majority of staff had undertaken further training on nutrition.

We also reviewed the progress the provider had made in dealing with complaints. There was evidence that the home was doing all it could to ensure people were aware of the complaints procedure. Staff told us they were aware of where they could find the complaints procedure and how they were to respond to a complaint. One relative we spoke with said" I have been given advice about how to complain if I should need to".

During this inspection we did not speak to people living in the home about their medicines. However we saw the nurse giving some people their lunch time medicines in a safe and respectful way.

This was an unannounced visit to the home following a meeting with staff from the local authority on 15 May 2012 where concerns about this service were discussed. Two inspectors visited the home, one a pharmacy inspector. This was due to significant concerns about the management of medicines in the home. We also followed up improvements we had asked for following our last inspection on 16 November 2011.

We spoke with eight people who lived in the home who told us that staff provided the care and support they needed. They said staff were patient and kind. One person told us “I’m alright living here. I do what I can for myself and the staff do the rest for me”.

People spent time alone if they chose to, either in communal areas or in their own rooms. We saw that people walked around the home independently or chose to sit in one of the home's lounge areas, the sensory room or in the garden. Staff checked on people regularly when they were not in communal areas and always knocked on doors before entering people's own rooms.

We spoke with two visitors. They told us that they were involved in decisions about their relative's care and that communication with the home was very good. They attended review meetings and said they spoke with the manager or the deputy when they visited. One relative said “they always keep you informed and I think that’s very good. There are always things going on here. There are lots of activities and things to keep people active. I think that is very important”.

People who lived in the home told us they felt well cared for and that staff understood what care and support they needed. One person said “they look after me very well here” and another person told us “I am very happy here. The staff look after me”.

The visitors we spoke with were very happy with the care staff provided. One

said “we are very impressed with the care in this home”. They told us their relative needed “help with their personal care and most things really”. They commented that their relative “is nice and clean, they have been shaved. They are looking really good, much better than before they came here”. Another visitor told us “my wife lives here and she always seems very happy. She seems really well cared for”.

People we spoke with said they thought the home was a safe place for them to live.

Relatives also told us they thought people were safe living at the home. People said they would raise any concerns if they had any and would be happy to share these with staff. One relative told us “I think it is safe place for my wife to live. I have never seen her unhappy or upset. I have never had any concerns about her safety or the care she receives”.

People who lived in the home said staff were available when they needed them. One person said “the staff are lovely to me” and another person told us “the staff look after me well. They are kind”. Two visitors said they felt there were enough staff to meet people’s needs. One told us “there are always enough staff. I have never seen them short of staff and have never seen the main rooms without staff”.

Most people were not able to look after their own medicines, so medicines were given by staff. We saw that arrangements in place for giving people their medicines did not always follow recommended good practice or the home’s own medicines policy. Many medicines had already been given in the morning of our inspection however these had not been signed as given on people’s medicines administration record sheets. We saw other examples where medicines administration record sheets did not show that people had been given their medicines as prescribed for them.

There was no written information for staff about how people liked to be given their medicines either with their medicines administration record sheet or in their care files. This meant that people may not be given their medicines in an appropriate and consistent way, no matter which staff were on duty. A medicines trolley was used to transport medicines safely around the home. However during our inspection four people’s medicines were put into labelled medicine pots and taken around the home to them without using the trolley. This increased the risk of medicines being dropped or put down, where they could have presented a hazard to people.

We spoke with a number of people who lived in the home who told us that staff provided the care and support they needed. They said staff were very patient and were kind to them. One person told us “the staff have all been very kind to me since I moved in, but I can still do some things for myself and they respect that”. Another person told us “it’s lovely here. I’m very happy. There’s lots going on and I can do the things I want to do. We go out as well and there are lovely grounds here”.

All of the relatives we spoke with were very happy with the care staff provided. One relative said “I have to say how very patient the staff are with everyone. All of the staff know mum and understand her needs. They couldn’t do any more for her”. Another relative said “”it’s absolutely wonderful care here, I couldn’t wish for a better place”.

Staff were aware of important events in people’s lives and ensured they provided personalised care. One relative said of his wife’s care “we had our wedding anniversary recently and they did a lovely card with our picture on it. They just do little things like that and it’s wonderful”. Another relative said “mum is nursed in bed now and they have made her room very personal to her so it feels like home. They even decorated her room on her birthday, it was lovely of them to do that”.

People we spoke with said they thought the home was a safe place for them to live. One person said “yes I do feel safe living here. There are always staff around”. Relatives also told us they thought people were safe living at the home; one relative told us “I never ever feel I need to worry for a minute. My wife gets the best care, she is safe and happy”.

People who lived in the home told us there were enough staff working in the home to meet their needs. Staff understood how to care for them. One person said “the staff are lovely, very kind”.

Relatives we spoke with said staff understood people’s needs and provided the care needed. One relative said “the staff are attentive and know what they are doing. You can always speak to staff about anything”.

Relatives we spoke with told us they felt able to raise any issues with the manager or the deputy; if they were not working in the home relatives would speak with nursing staff. One relative said “you can speak to staff about any problems. We have asked if mum can move rooms before and this was done”.

There are a number of people who live at Elroi Manor who have a diagnosis of a dementia and people who live at the home have varied, often limited, methods of communication.

This visit was carried out specifically to enable us to look into concerns we had about the care and support provided to people who have diabetes. We did spend some time in communal areas observing how staff were providing care to a number of people, but we did not speak in depth with people who live in the home during this visit.

We saw that staff, although they appeared very busy, provided care and support to people in a professional yet friendly way. They appeared to know people well and understood them. When people asked staff members for assistance this was provided reasonably quickly.

Following our last inspection on 19 November 2013 and 20 November 2013 we served three warning notices because people's choices about their day to day lives were limited or not respected by staff. Where people did not have the capacity to make decisions for themselves, the provider had not acted in accordance with legal requirements. Care and treatment was not planned or delivered in line with people's assessed care needs or plans of care or delivered in a way to ensure people's safety and welfare. There were not enough qualified, skilled and experienced staff to meet people's needs. This placed people at significant risk of harm.

We also found that care was not provided in an environment that was safe or adequately maintained. We issued a compliance action in respect of this.

At this inspection we found where people did not have the capacity to make decisions for themselves, the provider had still not acted in accordance with legal requirements.

People’s care and treatment was still not planned or delivered in line with their assessed care needs or plans of care or delivered in a way to ensure their safety and welfare. Care staff appeared kind and were trying to meet people’s needs but did not appear to have the necessary knowledge, skills or supervision to provide safe, effective and responsive care. There were ineffective arrangements in place to deal with foreseeable emergencies.

Care was still not provided in an environment that was safe or adequately maintained.

There were still not enough qualified, skilled and experienced staff to meet people's needs. Staff lacked knowledge of people’s care plans or risk assessments. There was no evidence that any checks were made to ensure that staff had understood their training and embedded it in their care practice. No formal staff supervision or appraisals were being carried out.

People who used the service and/or their representatives were asked for their views about their care but there was no evidence they were acted on. Roles and responsibilities within the management team were unclear. There was a confused approach in attempting to implement improvements.