The inspection of OSJCT The Elms commenced on 31 January 2018 and was unannounced. This inspection was prompted in part by the provider’s notification to CQC of a significant event. The information shared with CQC about the choking incident indicated potential concerns regarding people’s safe care and treatment. This inspection examined those risks and reported on the findings in the safe and well led questions. This incident is subject to a separate police and coroner investigation and as a result this inspection did not examine the circumstances of the incident.

This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘OSJCT The Elms’ on our website at ‘www.cqc.org.uk’. The last inspection report was carried out 14 and 15 June 2017. At this inspection the service was rated as “good” and was meeting all of the relevant regulations.

OSJCT The Elms provides residential and nursing care for up to 45 older people. At the time of our inspection 38 people were using the service. Some of the people living at the home were living with dementia or other long term health conditions. Some people were staying at The Elms for a short period of time before returning to their own homes.

The home has 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 and associated Regulations about how the service is run. The registered manager was on leave at the time of this inspection. An Area Operations Manager employed by the provider was managing the home on a day to day basis.

The service was safe. Where people were at risk of choking this had clearly been assessed and comprehensive guidance was available to care and nursing staff. Nursing and care staff understood people’s risks and knew how to ensure people were protected from these risks. Nursing, care and catering staff felt they had the skills and resources they needed to protect people from the risk of choking.

All staff, including agency care staff received a handover at the start of their shift. This ensured staff had current information on people’s needs and risks. Agency staff who were unfamiliar with people living at The Elms were supervised and only assisted a small number of people to ensure they understood people’s needs and risks and promote familiarity between people and agency staff.

Management systems were in place to ensure people were kept safe from preventable harm. The provider, registered manager and senior staff took action where shortfalls had been identified. The provider had learnt lessons from the incident to prevent future harm. These lessons were being shared with other homes operated by the provider.

We have a recommendation to the provider as part of our inspection, to further build on their good practice in relation to the actions they have taken to protect people from the risk of choking.

The Elms provides nursing, residential and respite care for up to 45 people, some of whom were living with dementia. At the time of our inspection 44 people were living there. The home is purpose built over two floors.

At the last inspection on 17 and 18 February 2015 the service was rated Good. At this inspection we found the service remained Good.

There was one breach of legal requirements at the last inspection in February 2015. Following this inspection the provider sent us an action plan detailing how they would address the shortfall that had been identified. At our comprehensive inspection on 14 and15 June 2017 the provider had followed their action plan with regard to safeguarding people at risk of abuse.

People were protected against the risks of potential abuse. People told us they felt safe in the home and staff knew about safeguarding people and reported any concerns. There were sufficient staff and recent additional permanent staff had ensured staffing levels had improved. Recruitment was thorough and remained ongoing to help ensure less agency staff were used. We found peoples medicines were managed safely and reviewed. Individual risks for people were minimised and risk assessments of the environment were completed to help ensure people lived in a safe home.

People were able to make their own choices and decisions about their care. They 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 supported this practice. People’s needs were met by staff who had access to the training they needed and had regular updates to their training. Staff were supported in their role and had regular individual meetings where they could discuss improvements to the service and their progress with senior staff. People had a choice of meals and their nutritional needs were met. People told us they liked the meals provided.

People had positive interactions with staff who respected their privacy and dignity. We observed staff were kind and compassionate to people and encouraged them to be independent. People’s wishes for the end of their life were recorded and reviewed with them.

People received personalised care responsive to their needs. People were assessed before they moved into the home and their care plans identified the care and support they needed which was regularly reviewed. People were supported by health and social care professionals who visited when required. There was a programme of activities provided every day by three part time activity organisers. There was a clear complaints procedure and people could use the suggestion box in the home.

The registered provider had quality assurance procedures to check the service was safe and people were supported to lead the life they wanted without restrictions. People and their supporters had opportunities to comment on the service and they were listened to. Staff felt well supported by the registered manager and were able to comment to help improve the service.

Further information is in the detailed findings below.

We visited this home in January 2013 and identified concerns. We saw little evidence that people were consulted about their care and there were limited opportunities for people to express their views. People told us that there was not enough to do and there was inadequate attention given to those people who did not engage in group activities. Some staff were not up to date with mandatory training or supervision. The standard of record keeping was poor and we could not be assured that people received the care and support they required. We judged that, given the extent of non-compliance found, systems to monitor quality and safety were not effective.

We returned to the home to check if improvements had been made. We spoke with staff and with the manager. We spoke with five people who lived at The Elms and two relatives. We observed how people were cared for and looked at their records.

People told us they were well cared for and were full of praise for the staff. One person said "I couldn't wish for better care. All of the staff are really lovely souls". The home had appointed a new activities coordinator and a range of activities was provided; however some people complained of being bored.

An active residents' forum ensured that people's views were listened to and acted upon. A new manager had introduced systems to ensure that the home ran more smoothly. Staff felt well supported and told us that team working and morale had improved. Record keeping had improved.

On the day of our visit a new home manager had just been appointed and was present, along with the area manager who had been covering the home for the last month.

We spoke with people who lived at The Elms and one relative. We observed how people were care for and we looked at their records. People were mostly positive about their experiences but one person felt undermined because they had not been fully involved in decisions about their care. We found little documentary evidence that people were consulted and involved in developing and reviewing their care plans, although we observed staff allowing people to make choices.

People's needs were assessed and care plans reviewed but we saw little meaningful evaluation to show how people’s needs were met. The standard of record keeping was generally poor, and we could not be assured that people received the care that was prescribed in their care plans. This was particularly the case for the most dependent and vulnerable people.

The home was clean and tidy and we observed staff taking appropriate steps to minimise the risk and spread of infection. Staff said they received adequate training and supervision but records did not support this. Some staff felt unsupported by management and felt that team working was poor.

There were monitoring systems in place but these were not sufficiently effective to provide assurance of quality and safety.

This unannounced inspection took place on 17 and 18 February 2015.

The Elms provides nursing, residential and respite care for up to 45 people, some of whom were living with dementia. At the time of our inspection 35 people were living there. The home is purpose built over two floors.

There was 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.

All staff had received safeguarding training and knew how to recognise abuse and what action to take to protect people from harm. The omission of recording and communicating important information between staff put a person at risk from harm when there was a change in their mental health. Arrangements were in place for people to see healthcare professionals when necessary but we identified this had not happened. This required improvement.

Risk assessments were completed to minimise risks to people’s health and welfare. People were supported by sufficient staff with the appropriate skills, experience and knowledge to meet their needs. However, people’s needs were not always met promptly and we made a recommendation for this to be monitored to ensure improvements were made. Recruitment procedures used ensured suitable staff were appointed.

Medicines policies and procedures were followed and medicines were managed safely.

People had a choice of food and their dietary needs were met. Where people were at risk of malnutrition steps were taken to monitor and improve nutrition to meet their requirements.

Staff spoke with people in a respectful and caring manner, using an appropriate volume and tone of voice, giving people time to respond. People told us they were well cared for and enjoyed the company of the staff. People were treated with dignity and respect and their privacy was protected.

People were asked their views about their care and how the home was run. Concerns were listened to at residents meetings, where all aspects of the service were discussed. People told us staff listened to what they had to say and on the whole improvements were made. Regular checks were made to ensure the service was safe and well maintained.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We completed this inspection at a time when the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009 were in force. However, the regulations changed on 1 April 2015; therefore this is what we have reported on. You can see what action we told the provider to take at the back of the full version of this report.