This was an unannounced inspection which took place on 28 March 2017.

Sutton in the Elms is a purpose built residential and nursing home situated in the village of Sutton in the Elms. Accommodation and communal space is over two floors and all rooms are for single occupancy. There are suitable shared areas and a secure garden. The home provides accommodation for up to 40 older people some of whom living with dementia. There were 38 people living at the home when we visited.

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.

We previously inspected this service on 10 December 2014 where we found the provider needed to make improvements. These were to help people remain safe, to ensure staff were supported through supervision to do their job effectively and to support staff to raise concerns should they have any.

Staff understood how to protect people from harm and abuse. Staff had received suitable training.

Risk assessments and associated management plans were in place to support people.

Enough suitably skilled and knowledgeable staff were deployed to meet the needs of the people using the service.

Medicines were appropriately managed in the service. People saw their GP and health specialists whenever necessary.

People were encouraged to be as independent as possible by staff who were suitably inducted, trained and supported.

The provider's recruitment process was robust and included checking prospective staff before they started to work at the home. The provider also included people who used the service in the process. This helped the provider to make safer recruitment decisions.

Staff understood the requirements of the Mental Capacity Act (2005) and understood how to obtain people's consent before they offered care and support. Staff knew how to support people to make decisions for themselves. Where people may have lacked the capacity to make their own decisions, the provider had followed the requirements of the Act.

People were being supported by staff who cared. They had built relationships with staff that were meaningful. People's dignity and privacy was being promoted and maintained by staff.

People enjoyed the food that was offered to them and were supported to maintain a healthy diet. They could choose what they ate and their preferences and requirements were known by staff.

Significant accidents or incidents had been reported to CQC and suitable action taken to lessen the risk of further issues.

Assessments and care plans were up to date and met the needs of people in the service. Staff were very centred on the needs of individuals.

People had mixed feelings about the level of activities and entertainments on offer.

Staff were clear about their roles and responsibilities. They knew how to raise concerns about the practice of a colleague if they had needed to and felt able to do this. Staff were able to make suggestions for how the service could improve. The registered manager promoted a positive and open culture within the service.

The provider had a suitable quality monitoring system in place and action had been taken where improvements were needed. However, an internal audit of medicines had not been undertaken by the provider.

This was an unannounced inspection which took place on 28 March 2017.

Sutton in the Elms is a purpose built residential and nursing home situated in the village of Sutton in the Elms. Accommodation and communal space is over two floors and all rooms are for single occupancy. There are suitable shared areas and a secure garden. The home provides accommodation for up to 40 older people some of whom living with dementia. There were 38 people living at the home when we visited.

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.

We previously inspected this service on 10 December 2014 where we found the provider needed to make improvements. These were to help people remain safe, to ensure staff were supported through supervision to do their job effectively and to support staff to raise concerns should they have any.

Staff understood how to protect people from harm and abuse. Staff had received suitable training.

Risk assessments and associated management plans were in place to support people.

Enough suitably skilled and knowledgeable staff were deployed to meet the needs of the people using the service.

Medicines were appropriately managed in the service. People saw their GP and health specialists whenever necessary.

People were encouraged to be as independent as possible by staff who were suitably inducted, trained and supported.

The provider's recruitment process was robust and included checking prospective staff before they started to work at the home. The provider also included people who used the service in the process. This helped the provider to make safer recruitment decisions.

Staff understood the requirements of the Mental Capacity Act (2005) and understood how to obtain people's consent before they offered care and support. Staff knew how to support people to make decisions for themselves. Where people may have lacked the capacity to make their own decisions, the provider had followed the requirements of the Act.

People were being supported by staff who cared. They had built relationships with staff that were meaningful. People's dignity and privacy was being promoted and maintained by staff.

People enjoyed the food that was offered to them and were supported to maintain a healthy diet. They could choose what they ate and their preferences and requirements were known by staff.

Significant accidents or incidents had been reported to CQC and suitable action taken to lessen the risk of further issues.

Assessments and care plans were up to date and met the needs of people in the service. Staff were very centred on the needs of individuals.

People had mixed feelings about the level of activities and entertainments on offer.

Staff were clear about their roles and responsibilities. They knew how to raise concerns about the practice of a colleague if they had needed to and felt able to do this. Staff were able to make suggestions for how the service could improve. The registered manager promoted a positive and open culture within the service.

The provider had a suitable quality monitoring system in place and action had been taken where improvements were needed. However, an internal audit of medicines had not been undertaken by the provider.

Our inspection team was made up of an inspector and an expert by experience in relation to care for elderly people and people with dementia. They helped answer our five questions.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People were treated with respect and dignity by most staff. We saw mainly good examples of how staff treated people with dignity and respect. However, a small number of staff did not refer to people by their preferred name. Not all staff wore name badges which meant that people could not always name staff. One person told us, "The staff are so nice to me but I don't know their names."

People told us they felt safe. They told us that staff usually responded quickly when they used their call alarms. One person told us they had waited "a long time" when they had used their alarm. The registered manager told us that call response times were not monitored.

People told us that they knew how they could raise concerns but one person expressed a lack of confidence about doing so. They told us they were worried about "being in the doghouse if they [staff] knew what I was saying." We spoke at length with the person but they did not raise any concerns that required action.

People received their medications at the right time. The provider had effective arrangements for the safe management of medicines.

Training records we looked at showed that most staff had received training about safeguarding vulnerable people. Staff we spoke with understood how to identify and report signs of abuse. Procedures were in place for managers and staff to learn from events such as accidents and incidents, complaints and staff concerns.

The home had policies and procedures in relation to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). This is legislation that protects vulnerable people who are or may become deprived of their liberty through the use of restraint, restriction of movement and control. However, of 46 staff involved in providing care, only a third had received training about MCA and DoLS.

The provider employed housekeeping staff who cleaned the home. We saw that people's bedrooms and communal areas were clean and tidy. One person who used the service described the home as "spotlessly clean."

Equipment used to assist people with transfers and mobility had been serviced and maintained. Staff had been trained to use that equipment. We saw staff using the equipment safely and effectively. This meant people were not put at unnecessary risk of harm.

The registered manager and administrative staff set staff rotas. People's care needs were taken into account when making decisions about the numbers and skills and experience of staff required.

Is the service effective?

People’s health and care needs were assessed with them or their relatives. Care plans included details of people's needs but information about how people were supported with those needs lacked detail. We saw care plans that included statements that people required support with their personal care but we saw no information about how they had been supported.

When we spoke with relatives they told us they were confident that the service provided good care. One relative told us, "I've no concerns whatsoever. The staff complete all the care routines they should." However, the quality of record keeping meant we could not always find evidence that routines had been completed.

People's nutritional needs were met and people who required support with eating their meals received appropriate support. However, we found that accurate records of people's fluid intake had not always been made.

Visitors were able to see people in private and visiting times were flexible.

Is the service caring?

People told us they were supported by kind and caring staff. One person told us, "All the staff are very kind." Another person said, "Most of them care for me and are lovely." We saw that care workers showed patience and gave encouragement when they supported people. Most staff used people's names when they spoke with them, but some staff used terms such as "chick", "sweetie" and "darling". We saw a person's request to be lifted and made more comfortable not acted upon.

People we spoke with were complimentary about the staff. One person said , "You couldn't better it. The staff are lovely. They come at night to see I'm comfortable." A relative of another person told us, "I am very pleased with the care for my wife, the care home is excellent."

People’s preferences, interests and diverse needs had been respected. People who wanted to be were supported with their religious and spiritual needs. People had newspapers of their choice to read. The home provided a range of communal and individual activities that people participated in.

Is the service responsive?

People told us that staff supported them with their needs. People told us they were well looked after. Most records we looked at showed that people had been supported with personal care and health needs. However, the quality of record keeping varied and a small number of records were incomplete or lacked detail. Where records lacked detail it was difficult to find evidence that people had been supported to the full extent of their care plan.

Most relatives we spoke with told us that they knew how to raise concerns and were confident they would be listened to. We saw that relative's complaints had been investigated and resolved. One relative wasn't sure about what the complaint's procedure was but they had no concerns.

All relatives we spoke with told us that the service had kept them informed about their parents or spouse's welfare.

People who used the service and relatives had participated in a satisfaction survey. The results of the survey showed that people were satisfied with their care. Relatives told us that their views had been acted on.

Is the service well-led?

The service had a system for monitoring the quality of service. This included checks of documentation and records.

The provider had carried out a survey of people who used the service. The survey gave people an opportunity to comment on their experience of the service.

A provider is required to report to us, without delay, instances of people being injured. We found there had been an instance of a person suffering a potentially serious injury several weeks before our inspection that we had not been informed about.

Some staff had been subject to disciplinary action because of inappropriate care practice and unprofessional conduct. We received information from two staff who expressed no confidence in the provider's willingness to look into concerns they had.

We spoke with 13 people using the service and with four relatives who were visiting at the time of our inspection. All those we spoke with were satisfied with the care and support that was provided. One of the relatives we met told us, “I have no complaints at all. The staff are kind and they treat my relative as an individual.”

A number of people told us that they felt there was a lack of opportunities for social and recreational activities. One told us that they couldn’t fault the way staff met their care needs but wished they had more time, “No one seems to have the time to talk to me.”

People told us that they were satisfied with the meals that they received and they had an opportunity to make choices about the food they ate.

At times there was a lack of staff available which meant that some delays were experienced when people requested assistance. One person explained to us that they felt staff were careful not to rush or hurry them, but they were still aware that they were under pressure, “You can tell there is something else they need to be doing”.

Staff had not received all the up to date training they should have had to help ensure that their skills and knowledge were up to date.

Records relating to people’s care and support were well organised and kept securely. They were destroyed safely when no longer required.

Prior to our inspection we asked the provider to send us written information in relation to this outcome area. We then made a visit to the home on 30 November 2012 to collect further information and to speak with people using the service and with staff.

This was a routine inspection but shortly after we began our inspection process we received information of concern about this service. We took this information into account as part of our inspection process.

The people we spoke with who were using the service told us that they were satisfied with the care and support they received.

During our inspection visit we spoke to five of the people who used the service and two relatives who were visiting at the time. People told us they were satisfied with the care and support they received. Their comments included;

“Staff come into my room and have a chat to see if everything is ok.”

“They look after me well.”

“Staff do lots of the little things that are lovely and make a difference.”

We spoke to some of the people who used the service and to some who were visiting the home at the time of our visit. People told us they were satisfied with the care and support they received and felt that staff looked after them well. They felt that if they had any concerns about the care they received they would be able to raise these. Those we spoke to who joined in the social activities on offer enjoyed these. Others told us they preferred being able to spend time quietly and occupy themselves.