This inspection took place on 16 and 19 April 2018 and was unannounced.

Ersham 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.

Ersham House is a detached building with the accommodation spread over two floors and at the time of the inspection people occupied rooms on the ground floor.

At our last inspection in August 2017, the service was rated Inadequate and placed in special measures and we took further enforcement. We asked the provider to take action and they sent us an action plan. The provider wrote to us to say what they would do to meet legal requirements in relation to the breaches we found. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements. This inspection found that whilst there were areas still to improve and embed in to everyday practice, there had been significant progress made and that they had now met the breaches of regulation. The service has been taken out of special measures.

A registered manager was not in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. The current manager took over in May 2017 and had been in post 11 months at the time of the inspection. They have submitted an application to become the registered manager. We have received confirmation that an interview had been organised for June 2018.

Since the last inspection quality monitoring systems had been improved and implemented so that shortfalls were being identified and acted upon. However, the provider will need to evidence that improvements can be sustained over time and when new people came to live at Ersham House.

The training programme identified that there were still staff that needed to undertake essential training to ensure that people received safe and effective care. This was an area that required improvement. Some staff supervisions recorded in 2017 were not of a high quality and, although these had improved in 2018 this improvement needs to be sustained to ensure staff are supported adequately.

There were individual care plans for people that identified their specific needs. However, we found that improvements were still needed in the care plans to guide staff in responding to people’s individual complex diabetic needs and those approaching their end of life.

We have made a recommendation that the registered provider seeks specialist training in diabetic care and end of life care to support staff in providing responsive care.

People were being kept safe from abuse. Staff understood their responsibilities in keeping people safe from abuse and had been trained. Staff knew how to report any possible concerns. People were supported safely around risks and were encouraged to take positive risks after control measures were applied. Environmental risks were managed safely and there were protections in place in relation to possible hazards such as fire. Staffing levels met people's needs and people told us that they could find staff to help them when they needed to and we observed staff were not rushed when helping people. People received their medicines safely and when they needed them by staff trained to administer them. Medicines were stored and managed safely. The risk from infection was reduced by effective assessments and cleaning rotas and the housekeeping team kept the home clean. When things went wrong the service had learned from accidents and incidents and had shared that learning with staff.

People had received an assessment of their needs and the

We inspected Ersham House Nursing Home on the 29 and 31 August 2017 and the inspection was unannounced. Ersham House Nursing Home provides accommodation and personal care, including nursing care, for up to 40 people. People had needs such as poor mobility, diabetes, as well as those living with various stages of dementia. The service also had a contract with the local authority to provide care and support for up to seven people to prevent unnecessary hospital admissions. There were 26 people living at the service on the days of our inspection.

An acting manager was in post but they were not yet registered with the commission. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. The registered manager left the service at the end of October 2016. A previous acting manager had been in post from October 2016 to April 2017. The current acting manager took over in May 2017 and had been in post four months at the time of the inspection and told us they would submit an application to become the registered manager.

At the last inspection undertaken on 28 and 29 February 2017, we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to; Regulation 9, people were at risk of social isolation. Regulation 11, people's care plans did not reflect their basic rights to consent and decision making. Regulation 12, evidence was not available to show that care was provided in a safe way and Regulation 17; effective systems were not in place to monitor the quality and safety of the service.

We asked the provider to take action to meet regulations 9 and 12. We took enforcement action against the provider and told them to meet Regulation 11 by 14 June 2017 and Regulation 17 by 14 July 2017. The provider sent us a report of the actions they were taking to comply with Regulations 9 and 12 and they told us they would be meeting these Regulations by 31 July 2017.

At this inspection we found the provider had made some improvements to the service and standards of care. Another activity coordinator had been recruited and staff no longer referred to people in an inappropriate manner. Prescribed fluid thickener was not left in easy reach of people. Staffing levels had increased and a dependency tool was now in place to assess what staffing levels were needed to meet people’s needs. However, many improvements had not been made and we found continuing breaches of regulations from the last inspection. We also found new breaches of regulation.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of Inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key

We inspected Ersham House Nursing Home on the 27 and 28 February 2017 and the inspection was unannounced. Ersham House Nursing Home provides care and support for up to 40 people who have nursing needs, including poor mobility or diabetes, as well as those living with various stages of dementia. The service also had a contract with the local authority to provide care and support for up to seven people to prevent unnecessary hospital admissions. There were 27 people living at the service on the days of our inspection.

An acting manager was in post but they were not the registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. The previous registered manager left the service at the end of October 2017 but they had not yet submitted an application to CQC to de-register. The acting manager had been in post four months at the time of the inspection and told us they would submit an application to become the registered manager.

At the last inspection undertaken on the 4 and 5 May 2016, we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 in relation to the principles of the Mental Capacity Act 2005 not being adhered to. Accurate and complete records had not been maintained and the management of medicines was not safe. The provider sent us an action plan stating they would have addressed all of these concerns by October 2016. At this inspection we found the provider had made improvements to the management of people’s medicines. However, improvements were not yet fully embedded and the provider continued to breach the regulations relating to the other areas.

The principles of the Mental Capacity Act (MCA) 2005 were still not consistently applied in practice. Bed rail risk assessments were not consistently in place and people’s capacity to consent to the use of bed rails had not consistently been assessed. Care plans were at times contradictory and failed to document and underpin whether people could consent to their care plans.

People spoke highly of the food provided and a nutritional champion was in post. Menus were devised in partnership with people and initiatives had been implemented to promote nutritional intake. However, where there was the risk of dehydration, improvements were required to the monitoring and oversight of people’s hydration needs. We have made a recommendation for improvement.

The risk of social isolation had not consistently been mitigated. The registered provider had failed to maintain accurate, complete and contemporaneous records. People's monitoring charts were incomplete and included unexplained gaps and omissions. Incidents and accidents were not consistently audited for emerging trends, themes or patterns. The management of diabetes was not consistently safe and prescribed fluid thickener had been left in easy reach of people which posed a risk.

People received their medicines on time and in a safe manner. However, documentation failed to confirm when people’s percutaneous endoscopic gastrostomy (PEG) tubes were last rotated. People felt staffing levels were insufficient and commented that staff presented as busy and the call bell was continually ringing. We have made a recommendation for improvement.

The management team were dedicated to the on-going improvements of Ersham House Nursing Home. A quality assurance framework was in place but the positive improvements were still in the process of being embedded and implemented.

People’s individual ability to evacuate the service has been assessed and evacuation plans were in place. However, people’s evacuation plans failed to highlight that the service would operate a ‘stay put’ policy at night. We have made a recom

We inspected Ersham House on 4th and 5th May 2016. This was an unannounced inspection. The service provides accommodation and support for up to 40 people. The service provides nursing care. At the time of inspection there were 25 people living at the service. The service provides en-suite rooms over two floors and has a lift. There are three communal lounges and dining room, kitchen, laundry, two clinical rooms and two nurse’s stations.

There was a manager in post who was registered with the CQC. 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 had not ensured that medicines were stored or managed safely at all times. Staff had left the medicine trolley unattended during inspection. There were gaps in the medicine administration records where staff should have signed to say they had given medicines.

The service was clean and tidy and there were effective cleaning procedures in place.

There were sufficient numbers of staff to keep people and safe and meet their needs. The provider had a system in place that allowed the registered manager to recruit more staff when the numbers of people living at the home increased.

Staff were trained to protect people from abuse and harm. Staff could identify the signs of abuse and who to report to if they had any concerns. Staff were familiar with policies and procedures to record, investigate and track any safeguarding concerns.

The principles of the Mental Capacity Act 2005 (MCA) were not consistently applied in practice. Where people were unable to give consent to aspects of their care an assessment of their capacity had not always been completed.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Appropriate application to restrict people’s freedom had been submitted and the least restrictive options were considered as per the Mental Capacity Act 2005.

People were supported to have a healthy and nutritious diet, and were given options on what they would like to eat. The provider had carried out appropriate risk assessments to identify if anyone required additional support managing their diet or eating.

People were being referred to health professionals when needed. Staff were referring people to their GP, dentists and dieticians when it was identified that a person had a change in need.

People and their relatives told us they were involved with the reviews of their care plans. Care plans were being reviewed on a regular basis. However, the provider had not ensured that effective systems were in place to record who had taken part in reviews.

People told us they were very happy with the care staff and felt supported with their care. Staff were seen to be kind and caring towards people living at the service.

People’s private information and personal documentation was not always safely stored. People’s personal information was, on one noticed occasion, left unlocked in a drawer and unattended in an area that was passed by visitors. The registered manager had not ensured that all people’s records were up to date. Staff were aware of any changes to people’s care but these changes were not always transferred to the care plans.

People at the service were encouraged to make their own choices. People were free to decorate their rooms to their own tastes and preferences. People could choose which activities they participated in during the day.

People were encouraged to give feedback on their experiences. People completed surveys that identified where improvements can be made. The provider had in place an effective system to fully investigate complaints. People and staff spoke positively about the registered manager

An adult social care inspector carried out this inspection. The focus of the inspection was to our 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 people using the service, their relatives, visitors and the staff told us, what we observed and the records we looked at. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. We saw that care plans reflected issues that were identified in the assessment.

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. Relevant staff have been trained to understand when an application should be made, and how to submit one.

We looked at the physical environment and found bedrooms and communal areas to be clean and well maintained. However, we also found the floor and walls around the oven in the kitchen were dirty with no evidence of recent cleaning. There was thick grease and grime on areas around the kitchen appliance and food debris on the floor. This indicated a lack of thorough cleaning. We have asked the provider to take action.

All of the staff we spoke with told us that staffing levels at the home were insufficient to meet the needs of the people who lived there. We were repeatedly told that due to the high dependency needs of the people accommodated, the current staffing ratio meant that staff did not have sufficient time to do, “More than basic care.” Staff told us that staffing levels were especially challenging in the afternoons and at mealtimes. We have asked the provider to take action.

Is the service effective?

People and their relatives told us that they were happy with the care provided and felt their care needs had been met. Staff told us they understood people’s care needs and that they knew them well. We read the following feedback, ‘The care you provide was both professional and sensitive and it is such a relief to know [my relative] is in safe hands.’

People who were able to verbally communicate with us told us that the meals they received were generally good and they received choice at each mealtime. We saw evidence in care plans that people's nutritional needs had been assessed. During the inspection however, we observed that advice and guidelines were not always followed which meant that people were not appropriately supported with their food and drink. We have asked the provider to take action.

Is the service caring?

We saw that staff communicated with people at a suitable relaxed and considerate pace. All of the people we spoke with told us they were happy at Ersham House Nursing Home. A relative told us, “The staff are so kind and friendly. I can’t fault the care [my relative] is in good hands here.”

Is the service responsive?

Care and nursing staff told us about each person’s care needs and support required. One member of staff told us, “People are well cared for here, we know their needs.” We saw that a GP had recorded the comment, ‘Excellent nursing home. Staff liaise effectively with primary care.’

Is the service well-led?

People, their representatives and staff were asked for their views about their care and treatment and they were acted on.

Quality and compliance audits were regularly conducted and included medication, accident and incidents, care plans and maintenance reviews.

We carried out this inspection to follow up on a warning notice issued as a result of concerns identified at the last inspection.

We considered our inspection findings to answer questions we always ask:

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

Is the service safe?

Systems were in place to ensure that the management and staff had learnt from issues identified at previous inspections. This reduced the risks to people and helped the service continually improve.

If the service effective?

People's health and care needs had been assessed, and people told us the staff always asked them if they needed assistance.

Is the service caring?

We saw that staff were aware of people's needs and offered kind and considerate support. One person said, "The staff are very good, they know exactly what help I need".

Is the service responsive?

A range of social activities were available for people to join in if they wished. The programme was flexible and we saw that people made choices.

Is the service well-led?

The home worked well with other agencies and sought advice and support as required.

The staff we spoke were clear about their roles and responsibilities, and they had a good understanding of people individual needs.

We carried out this inspection at Ersham House to follow up on an outstanding issue with regard to record keeping, which we found during our previous inspection of 17 September 2013.

We used a number of different methods to help us understand the experiences of people who used the service. Some people had complex needs, which meant they were not able to tell us their experiences. However, those who spoke with us said, ‘I like living here’ and ‘The food is very nice’.

We examined three care plans. We found that there were inconsistencies in the information recorded, and the way records were kept.

We visited Ersham House and spoke with 10 of the 41 people who lived there, two relatives and a visitor. We used a number of different methods to help us understand the experiences of people who used the service, because some people had complex needs which meant they were not able to tell us their experiences.

People who were able to speak to us said they were very comfortable living at Ersham House. One person said, "I am quite comfortable. We have everything we need and the staff are very good." We observed that staff were respectful and caring and asked people if they needed assistance. People decided how and where they spent their time.

We examined four care plans. We found they identified people's specific needs and that people and their relatives, if appropriate, were involved in making decisions about the care provided. Some of the care documentation had not been completed, although staff were able to demonstrate a good understanding of people's needs.

Policies and procedures for safeguarding people were in place and staff had attended the relevant training.

We looked at the management of medicines and found that the systems used were appropriate.

We looked at staff files, training records and spoke with five care workers and two nurses. The training matrix identified the training people had attended or were booked to attend.

A complaints procedure was in place and people told us they felt confident to discuss any issues with staff or the manager.

Due to people’s complex needs, some people were not able to tell us about their experiences. We used a number of different methods such as observation of care and reviewing of records to help us understand the experiences of people using the service.

People we were able to speak with who lived in the home told us “I can’t fault the staff, they respect my privacy and always knock before they come into my room. I go out when it pleases me, I just let staff know where I am off to”

We were unable to talk to many visitors on this occasion, but one visitor told us that they were more than happy with the home. A visiting professional told us, “staff are always very polite and helpful”.

Some people we spoke to were able to tell us that they enjoyed living at Ersham House, and were happy. We were told “everyone is very nice” “I am really happy here” and “the food is always very good”.