The Elms Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The home is registered to accommodate 18 older people some living with dementia and mental health difficulties; at the time of our inspection, there were 17 people living in the home.

At our last inspection in September 2016, this service was rated overall as good. At this inspection, we found that the service had deteriorated and has been rated as requires improvement. This is the third time the service has been rated as requires improvement in the last three years.

The inspection took place on the 31 July and 6 August 2018 and was unannounced.

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. The registered manager was absent at the time of the inspection and the service was being managed by a newly appointed deputy manager, supported by the provider.

There was not always sufficient staff with the right skills deployed to meet everyone’s needs. People’s access to activities in and outside of the home was limited.

The home was not well maintained and access to the garden was limited due to the poor maintenance of the paths. Areas of the home needed redecoration and refurbishment. We have made a recommendation about the access to the garden.

Care plans were basic and lacked the detail to support staff to provide person-centred care. However, the provider was aware of this and was in the process of introducing new care plans which were person-centred and would contain the detail staff needed to provide consistent care and support.

The systems in place to monitor the quality of care and effectiveness of the service had not been consistently maintained. Audits had not been regularly undertaken so any shortfalls had not been identified. The provider was working with the local authority to address this.

People were supported to have choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice. People’s health care and nutritional needs were considered and relevant health care professionals were appropriately involved in people’s care.

People received care from staff that knew them and were kind, compassionate and respectful. The staff were friendly, caring and passionate about the care and support they delivered. However, people’s dignity was not always protected.

Staff were appropriately recruited. People received their prescribed medicines safely. Staff understood their responsibilities to keep people safe from any risk or harm and knew how to respond if they had any concerns.

Staff had access to the support, supervision and training that they required. However, induction training for new staff needed to be improved and access to specialist training would be of benefit.

The service had a positive ethos and an open culture. People knew how to raise a concern or make a complaint and the provider had implemented effective systems to manage any complaints that they may receive.

At this inspection, we found the service to be in breach of three regulations of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014. The actions we have taken are detailed at the end of this report.

We inspected the service on 8 August 2016 and the visit was unannounced.

At the last inspection on 6 January 2016 we asked the provider to take action to make improvements. We asked them to improve their practice in relation to obtaining people’s consent to care and to follow the requirements of the Mental Capacity Act 2005 (MCA). We also asked the provider to improve staff members’ understanding of the requirements of the Act. Following that inspection the provider sent us an action plan setting out what they were going to do. At this inspection we found that the provider had made the required improvements.

The Elms Residential Home provides care and support for up to 18 older people. At the time of our inspection 18 people were using the service and many had dementia or similar conditions. The accommodation is offered over two floors accessible by a passenger lift and stairs. There is a communal lounge, dining area and conservatory on the ground floor along with some of the bedrooms, and the remaining bedrooms are on the first floor. There is a large well-maintained accessible garden for people to use should they wish to.

At the time of our inspection there was a registered manager in place. It is a requirement that the service 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 2008 and associated Regulations about how the service is run.

People and their relatives felt safe with the support offered. Staff understood their responsibilities to protect people from abuse and avoidable harm and to remain safe. The registered manager dealt with accidents and incidents appropriately. Risks to people’s health and well-being had been regularly assessed. For example, where people’s skin condition could have become injured, staff followed guidance the registered manager had made available to them.

The provider had a thorough recruitment process in place for prospective staff. This included checks on the suitability of staff to work in the caring profession. People, relatives and staff were largely satisfied with the number of staff available to offer care and support and we found that staffing levels were suitable to help people to remain safe.

People received their prescribed medicines in a safe way. Staff followed national guidance when offering people their medicines and received training to understand their responsibilities. Medicines were stored appropriately and guidance was available and followed by staff about how people preferred to take them.

People received care and support from staff with the appropriate knowledge and skills. Staff had received regular training such as emergency first aid. New staff received an induction when they started to work for the provider. They had regular meetings with the registered manager so that they could receive feedback and guidance on their work.

People were supported in line with the Mental Capacity Act 2005 (MCA). People consented to their support where they could. The registered manager had assessed people’s mental capacity where this was necessary and decisions were made in people’s best interests. Staff understood their responsibilities under the Act. The registered manager had made applications to the appropriate body where they had sought to deprive a person of their liberties.

People chose what they ate and drank and were largely satisfied with what was offered to them. People had access to healthcare services such as to their GP. People’s health conditions had been recorded in their care records so staff knew how to provide effective support.

People received support from staff who showed kindness and compassion. Staff protected their dignity and privacy and showed respect for people. People’s friends and relatives could vi

We inspected the service on 6 January 2016 and the visit was unannounced.

At the last inspection on 10 November 2014 we asked the provider to take action to make improvements. We asked them to improve their practice in relation to the arrangements for monitoring the quality of the service and delivering improvement. We also asked the provider to improve their practice in relation to obtaining people’s consent to care. Following that inspection the provider sent us an action plan detailing what they were going to do to make improvements. We found that although improvements had been made to monitoring the quality of the service, the provider had still not fully considered people’s consent in line with the Mental Capacity Act 2005. You can see what action we told the provider to take at the back of the full version of the report.

The Elms Residential Home provides residential care for up to 18 older people. There were 18 people using the service at the time of our inspection, the majority of whom were living with a dementia-type condition. The accommodation was provided over two floors and there was access to the upper floor via a passenger lift or stairs. There was a large accessible garden that people could use.

It is a requirement that the home has a 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 2008 and associated Regulations about how the service is run. At the time of our inspection there was a registered manager in place.

People told us that they felt safe. Staff were aware of how to keep people safe through the training they had undertaken and knew how to report actual or suspicions of abuse.

Risks to people had largely been addressed and documented but the records sometimes lacked detailed information for staff to follow. We found that people did not always have a call bell available to help them to keep safe.

The home and equipment were being regularly checked so that people were safe. However, some records were not always up to date to verify this. Some plans to evacuate people from the home if needed were not always complete.

Staffing levels were appropriate to keep people safe during our visit. Feedback from relatives and staff members suggested that staffing levels needed to be looked at during the night. Recruitment of new staff was robust and the registered manager had carried out checks on prospective staff before they worked for the provider.

People received the medicines that they needed. We saw that there were systems and policies in place to make sure medicines were being handled safely.

We saw that staff members had received regular training, including dementia training, which was important for the people they offered support to. However, we found that best practice in relation to dementia care and support was not always in place.

People were given choices regarding food but sometimes these were in ways that they could not understand.

People’s consent to care had not been fully considered. Where people may have lacked the capacity to make decisions for themselves, the provider had not made arrangements for appropriate mental capacity assessments to be undertaken. We also saw that decisions made in a person’s best interest had not been documented. We found that staff had undertaken training in the Mental Capacity Act 2005 but they did not show a good understanding of this legislation. We identified that these matters constituted a breach of the regulation where there service had failed to act in accordance with the provisions of the Mental Capacity Act 2005.

People enjoyed the food offered to them. However, where people were receiving a soft diet it was not clear whether this was a person’s preference or if the home had put this in place.

People had access to a GP when required and we found that people received regular support from a chiropodist and dentist.

People told us that the staff were caring. We saw that staff offered support in a kind way. However, we found that staff did not spend quality time engaging with people and focused mainly on practical tasks.

People’s preferences were detailed in their care plans and we found things that were important for people to be in place. For example, a person’s preferences for their bedding had been addressed by staff.

Records did not show how people had been involved in decisions about their care. Relatives had not always been invited to be involved in their family member’s care planning.

People were largely receiving the care they required in line with their care plans. For example, people were being assisted to turn to prevent pressure ulcers from developing. However, where soft diets were given, these had not been carefully care planned.

People’s care plans were being reviewed regularly to give staff up to date information about people. However, the reviews did not identify incorrect information.

People had mixed views on the activities being offered. We found that the planned activities did not all happen on the day of our visit.

People felt listened to and knew how to make a complaint if they needed to. The registered manager had dealt effectively with any complaints received.

The registered manager had audited the service regularly. However, the audits had not identified what we found on the day of our visit. For example, we found call bells were not available to some people.

Staff told us that they felt the registered manager was approachable and that they felt supported. We saw that the registered manager offered guidance and support to staff members.

There was a shared understanding within the staff team about what the service strove to achieve which was high quality care.

Relatives had mixed views about whether the provider had sought feedback on the service. Where it had been sought, the results of the quality assurance process had not been shared.

The registered manager was aware of their role and responsibilities and made the correct notifications to the relevant authorities.

We inspected the service on 6 January 2016 and the visit was unannounced.

At the last inspection on 10 November 2014 we asked the provider to take action to make improvements. We asked them to improve their practice in relation to the arrangements for monitoring the quality of the service and delivering improvement. We also asked the provider to improve their practice in relation to obtaining people’s consent to care. Following that inspection the provider sent us an action plan detailing what they were going to do to make improvements. We found that although improvements had been made to monitoring the quality of the service, the provider had still not fully considered people’s consent in line with the Mental Capacity Act 2005. You can see what action we told the provider to take at the back of the full version of the report.

The Elms Residential Home provides residential care for up to 18 older people. There were 18 people using the service at the time of our inspection, the majority of whom were living with a dementia-type condition. The accommodation was provided over two floors and there was access to the upper floor via a passenger lift or stairs. There was a large accessible garden that people could use.

It is a requirement that the home has a 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 2008 and associated Regulations about how the service is run. At the time of our inspection there was a registered manager in place.

People told us that they felt safe. Staff were aware of how to keep people safe through the training they had undertaken and knew how to report actual or suspicions of abuse.

Risks to people had largely been addressed and documented but the records sometimes lacked detailed information for staff to follow. We found that people did not always have a call bell available to help them to keep safe.

The home and equipment were being regularly checked so that people were safe. However, some records were not always up to date to verify this. Some plans to evacuate people from the home if needed were not always complete.

Staffing levels were appropriate to keep people safe during our visit. Feedback from relatives and staff members suggested that staffing levels needed to be looked at during the night. Recruitment of new staff was robust and the registered manager had carried out checks on prospective staff before they worked for the provider.

People received the medicines that they needed. We saw that there were systems and policies in place to make sure medicines were being handled safely.

We saw that staff members had received regular training, including dementia training, which was important for the people they offered support to. However, we found that best practice in relation to dementia care and support was not always in place.

People were given choices regarding food but sometimes these were in ways that they could not understand.

People’s consent to care had not been fully considered. Where people may have lacked the capacity to make decisions for themselves, the provider had not made arrangements for appropriate mental capacity assessments to be undertaken. We also saw that decisions made in a person’s best interest had not been documented. We found that staff had undertaken training in the Mental Capacity Act 2005 but they did not show a good understanding of this legislation. We identified that these matters constituted a breach of the regulation where there service had failed to act in accordance with the provisions of the Mental Capacity Act 2005.

People enjoyed the food offered to them. However, where people were receiving a soft diet it was not clear whether this was a person’s preference or if the home had put this in place.

People had access to a GP when required and we found that people received regular support from a chiropodist and dentist.

People told us that the staff were caring. We saw that staff offered support in a kind way. However, we found that staff did not spend quality time engaging with people and focused mainly on practical tasks.

People’s preferences were detailed in their care plans and we found things that were important for people to be in place. For example, a person’s preferences for their bedding had been addressed by staff.

Records did not show how people had been involved in decisions about their care. Relatives had not always been invited to be involved in their family member’s care planning.

People were largely receiving the care they required in line with their care plans. For example, people were being assisted to turn to prevent pressure ulcers from developing. However, where soft diets were given, these had not been carefully care planned.

People’s care plans were being reviewed regularly to give staff up to date information about people. However, the reviews did not identify incorrect information.

People had mixed views on the activities being offered. We found that the planned activities did not all happen on the day of our visit.

People felt listened to and knew how to make a complaint if they needed to. The registered manager had dealt effectively with any complaints received.

The registered manager had audited the service regularly. However, the audits had not identified what we found on the day of our visit. For example, we found call bells were not available to some people.

Staff told us that they felt the registered manager was approachable and that they felt supported. We saw that the registered manager offered guidance and support to staff members.

There was a shared understanding within the staff team about what the service strove to achieve which was high quality care.

Relatives had mixed views about whether the provider had sought feedback on the service. Where it had been sought, the results of the quality assurance process had not been shared.

The registered manager was aware of their role and responsibilities and made the correct notifications to the relevant authorities.

This inspection took place on 10 November 2014. It was unannounced inspection. Our inspection was planned at short notice because of concerns we received about how staff may have been behaving towards people who used the service and standards of cleanliness and infection control.

The Elms is a small home providing residential care for up to 18 older people. There were 16 people using the service at the time of our inspection. Most people using the service had a dementia type illness.

The service had 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.

People told us they felt safe at the service. Plans of care contained risk assessments associated with people’s care routines, but we saw one plan of care where the risks associated with using mobility equipment had not been assessed. We saw some instances where risks were taken inappropriately and guidance about storage of cleaning equipment had not been followed. The registered manager took prompt action to remedy these matters.

Staffing levels were based on dependency levels of people who used the service. Enough staff were on duty to meet people’s needs. The provider had recruitment procedures that ensured as far as possible that only people suited to work at the serve were employed.

The provider had arrangements for the safe management of people’s medicines.

Most of the people who used the service had difficulty with their hearing or were deaf. Staff did not have the necessary skills, training, information or guidance to be able to communicate effectively with them. After we discussed this with the registered manager they ordered a supply of communication signs designed for use in care homes.

People who were able had opportunities to make suggestions and provide feedback about what they thought of the service.

No person who used the service had a mental capacity assessment, which meant that people’s consent to care and support had not always been sought in line with the Mental Capacity Act 2005. The provider was not meeting the requirements of the law in relation to obtaining and acting in accordance with the consent of people who used the service. The provider had met requirements of the Deprivation of Liberty Safeguards. Use of restraint at the service had been authorised by the appropriate body. Staff had variable understanding of MCA and DoLS.

People were supported with their nutritional needs. They were able to choose what they ate. People who required support with eating received appropriate support. Staff supported people to maintain their health. Staff monitored people’s health and made appropriate referrals to healthcare professionals. Staff supported people to attend appointments with dentists, opticians and other health professionals.

Staff were caring and treated people with kindness. However they did not always protect people’s dignity. We saw two instances were staff had not protected people’s modesty when they helped lift them. The registered manager took prompt action to remedy this.

The manager and staff shared a vision about what the service wanted to achieve. People who used the service and relatives were involved in the development of the service. The registered manager had not reported all incidents where people had suffered injuries to the local authority and Care Quality Commission. The provider did not have adequate arrangements for the effective monitoring of the quality of the service or delivering improvement.

We found that the provider was in breach of two regulations. You can see what action we told the provider to take at the back of the full version of the report.

We carried out this inspection to check that the provider had made the improvements we had previously asked for. We did not speak to people using the service as part of this.

Improvements had been made and a policy introduced to explain how long records should be retained for. Documents had been sorted in line with this policy and disposed of if not needed.

During our inspection we spoke with seven of the people using the service. They all told us that they were satisfied with the care and support they received at The Elms. One person told us, “The staff here are always friendly, always nice.” And another added, “I am very happy with the way I get looked after. No complaints from me.”

People’s weight was monitored to help identify if there were any patterns of concern and nutritional assessments had been completed.

The people we spoke with also told us that they were satisfied with the building and with their individual bedrooms. One person said, “I have had my room decorated, I like the colours. I am very pleased with it.”

Staff we spoke with told us that they found their colleagues and the manager of the home to be supportive. They added that if they had any concerns they would not hesitate to raise these with the manager.

Records were kept stored safely but information was kept indefinitely and there were no arrangements for the secure destruction of confidential documents. We have asked the provider to take action to address this.

People who used the service at The Elms told us that they were satisfied with the care and support they received. One told us, “The staff are very nice to me, very polite.” Another said, “They (the staff) are always very good and go out of their way to help.”

Care plans and assessments were up to date and well detailed. They included information about people’s individual needs and preferences. Staff responded to people’s requests for help promptly. They spoke to people in a respectful, friendly manner and referred to them by their preferred names.

Improvements had been made to the layout and décor of communal areas and bedrooms, with further refurbishment work planned.

We spoke with three people who used the service. They told us:

“It’s nice here. There are a few things to do.”

“I’ve found it very satisfactory living here. I have a lovely room. The food is good.”

“We’re free to do what we want. It’s a nice atmosphere here.”

“I don’t get bored. We talk amongst ourselves. The carers take time to talk with us. The carers are good with people who are not as able to cope as others.”

A relative told us, “The carers had done an absolutely fantastic job. The care has been second to none. My mother would never have got to her age without the support of the carers.”

A carer we spoke with told us that they liked working at the home and that they felt supported because of the training and developmental opportunities they’d had.