What life is like for people using this service: Following our previous inspection the provider had made the decision to retire. At the time of our inspection staff were anticipating a change in ownership and we found the provider had been open and transparent with people and staff about the anticipated changes.

At this inspection we identified shortfalls in both ‘Is the service Safe’ and ‘Is the service Well-led’ key questions and have rated the service ‘Requires Improvement’ overall.

Staff were committed to providing good quality care but the service was not consistently safe. We found people’s needs had not always been comprehensively assessed and staff did not always have the information they needed to understand how to support people to remain safe. We found people who required moving and handling support and those who required support to manage their behaviour did not always receive care in accordance with current best practice guidelines.

The provider and registered manager continuously worked to improve the service. Following our inspection feedback the provider took immediate action to increase staffing in the afternoons so that people could have staff support when they needed it. Additional staff training had also been arranged.

The provider had reviewed their internal quality assurance systems to ensure a more comprehensive audit of the service was completed. The audits had effectively identified most of the shortfalls we found prior to our inspection. However, progress against the provider’s action plan had been slow and the provider’s area operation manager was working alongside the registered manager to make the required improvements.

More information can be found in the Detailed Findings below.

Rating at last inspection: Good (Report published on 4 April 2017)

About the service: The Elms Care Home with Nursing accommodates up to 22 older people in one adapted building. 13 people were using the service at the time of this inspection. Some people using the service were living with dementia, physical disability and/or sensory impairment.

Why we inspected: This inspection was prompted by concerns raised by a health professional regarding people's safe care and treatment. The information shared with CQC indicated potential concerns about the management of risk relating to safeguarding, response to deterioration in people’s physical health and safe moving and handling techniques. This inspection examined those risks.

This was the second concern raised to CQC about the service within the last 12 months. In December 2017, similar concerns had been raised by a health professional and relatives, relating to one person’s care and treatment. This concern was shared with the Local Authority who found action had been taken by the registered manager to address shortfalls in the care provided.

We inspected the service against two of the five questions we ask about services: Is the service safe? and Is the service well-led? No risks, concerns or significant improvement were identified in the remaining three 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.

Follow up: We will meet with the provider following this report being published to discuss how they will make changes to ensure the provider improves the rating of the service to at least Good. We will revisit the service in the future to check if improvements have been made.

The inspection took place on the 23 February 2017 and was unannounced. We previously inspected the service on 30 September and 5 October 2015 where we found a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to the management of risks in the care home environment and some areas of the management of people’s medicines. Before this inspection we also received some information of concern from a representative of a person using the service relating to the environment of the care home.

The Elms Care Home with Nursing provides nursing and residential care for up to 22 older adults. At the time of our inspection visit there were 12 people using the service.

We found improvements to the management of risks to people from fire and legionella.

We also found improvements to how people’s medicines were managed when prescribed to be taken on an ‘as required’ basis.

We identified some issues with doors in people’s rooms. The manager confirmed the doors had been reviewed and work had started to improve the safety of the doors.

At the time of our inspection visit The Elms Care Home with Nursing did not have a registered manager in post. The current manager was in the process of making an application for registration. 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 spoke with five people who use the service and two people's relatives, who visited during our inspection. We found that people’s wishes had been documented and where possible they or their representatives had signed their care plans to indicate that they agreed with them. One person said, “If I said I didn’t want something they (staff) would respect this”.

Records showed that where risks had been identified, staff had monitored people closely and had taken timely action when indicated. We saw that when staff had reviewed people’s care they had taken all relevant information into account and their interventions had been based on current research and guidance. This meant that risks to people were managed effectively.

There were effective recruitment and selection processes in place. This was evidenced by the low staff turnover at the home and by positive feedback from people who use the service and their relatives. One person said about staff, “I have no complaints at all… they listen to you and when you ring the bell or anything they don’t moan about it… it’s the little things they tell you about that are helpful”.

Effective quality monitoring systems were in place. People told us that they would recommend The Elms. Two people we spoke with had originally been admitted for respite care but had decided they did not want to leave. One said, “I came here for three weeks and have stayed three months. I’ve been looked after and I decided that I wanted to stay”.

People and their relatives were positive about their experiences of The Elms. One person who had recently moved from living at home said “I like it here; I have no regrets whatsoever… I couldn’t wish for a better place”. Another person who had lived there for over 10 years said “I’ve got no grumbles about anything; we get good food and a good bed, what more do old people want”. One relative said staff are careful and explain everything. Another relative said “it’s important for staff to be open and thorough these days, they have to be transparent, they do that here.”

We last inspected in September 2013 and found the provider was meeting all of the requirements of the regulations at that time. This inspection was unannounced and took place over two days on the 30 September and 5 October 2015.

The service provides long-term or short-term (respite) care for up to 31 older people who have a mixture of physical needs. Some people also live with dementia and some live with mental health needs. Accommodation is arranged over three floors with a bathroom on each floor, 29 of the 31 rooms have en-suite facilities. People living at The Elms have access to a large lounge and dining area and patio garden. At the time of our inspection there were 14 people living at the home. The home is required to have a registered manager in post.

The registered manager had been registered as manager at the service since September 2012. 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 found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

People were at risk of receiving medicines inappropriately. Protocols were not in place to guide staff in the use of ‘as required’ medicines. The premises were not always safe as testing for legionella in the home’s water supply systems had not been carried out. The home’s fire risk assessment was insufficient, as all required information had not been included. Information about people’s personal evacuation needs in case of emergency were not easy to access or sufficiently clear for emergency services personnel to use effectively.

Risks to people’s personal health were managed effectively as their changing needs were recognised and advice from community professionals was taken when needed, to help manage people’s well-being. People felt safe at The Elms and had good relationships with the staff who cared for them. They enjoyed a range of activities, spent their day as they wished and enjoyed regular visits from their relatives. They had plenty to eat and drink and any special dietary needs or requests were met. People had confidence in the staff and their skills and never had to wait long for assistance. They benefitted from living in a well organised and managed home where their needs were put first.

Staff enjoyed working at The Elms and felt supported in their roles. Staff were clear about their responsibilities to people and felt well-prepared to meet the needs of the people they supported. They told us there were enough staff to meet people’s needs. They were not rushed and had time to talk with people. Staff benefitted from learning opportunities and good communication within the home. They were able to request training or support when they needed it and felt comfortable to go to the registered manager with any concerns or suggestions to improve care. Staff knew people well and understood their changing needs. They cared about the people they supported. They supported their colleagues and worked as a team.

The culture at The Elms was open all staff upheld the providers values. Managers provided clear leadership to staff, they understood people’s needs and knew what was going on in the home on a day to day basis. Quality assurance processes were robust and action plans to improve the service were completed in a timely way. The provider was supportive and was in regular contact with managers to oversee running of the service. Learning was shared from within and outside the organisation and good community contacts were maintained to ensure care was up to date with current guidance.