The Elms is a care home without nursing which is registered to provide a service for up to ten people with learning disabilities and some with physical disabilities. Some people had other associated difficulties such as being on the autistic spectrum. There were eight people living in the service with one in hospital on the day of the visit. All accommodation is provided within a detached two story building within a village style development.

At the last inspection on 7 January 2016 the service was rated Good overall.

This unannounced inspection took place on 9 April 2018. At this inspection we found the service remained Good overall. However, we noted that care plans were not always completely up to date and reviews including risk assessments had not been undertaken to the required frequency. As a result the responsive domain has been rated Requires Improvement.

Why the service is rated Good overall:

There is a registered manager running the service. 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’s safety was contributed to by staff who had been trained in safeguarding vulnerable adults and health and safety policies and procedures. Staff understood how to protect people and who to alert if they had any concerns. General risks and risks to individuals were identified and appropriate action was taken to reduce them.

There were enough staff on duty at most times to meet people’s diverse, individual needs safely. The service had a stable staff team. The service had robust recruitment procedures. People were given their medicines safely, at the right times and in the right amounts by trained and competent staff.

The service remained effective. Staff were well-trained and able to meet people’s health and well-being needs. They were able to respond effectively to people’s current and changing needs. The service sought advice from and worked with health and other professionals to ensure they met people’s needs.

People were encouraged 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 practise.

The service continued to be caring and responsive. The committed, attentive and knowledgeable staff team provided care with kindness and respect. Individualised care planning ensured people’s equality and diversity was respected. People were provided with some activities, according to their needs, abilities, health and preferences. Care plans had not been reviewed by management for some time. Some care plans did not contain the most up to date information and records indicated that some risk assessments were not always reviewed within stated timescales.

The registered manager was well regarded and respected. The quality of care the service provided continued to be reviewed and improved, as necessary.

This inspection took place on 5 and 7 January 2016 and was unannounced. The Elms is a residential care home for people with learning disabilities and associated physical disabilities. It can provide accommodation and personal care for up to eleven people at any one time. On the day of the inspection nine people were using the service.

At the time of the inspection there was not 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 provider completed recruitment checks on potential members of staff. Essential maintenance of the property was carried out promptly but more routine issues could take longer and occasionally required chasing by the manager. Checks on fire alarms and emergency lighting had been completed in accordance with the provider’s policy and manufacturer’s instructions.

There was a system to ensure people received their medicines safely and appropriately. There had been three medication errors in the previous year which had resulted in a complete review of the system for medicines management. The quality of the service was monitored by the acting manager through gaining regular feedback from people and their representatives and periodic auditing of the service. The provider had plans in place to deal with emergencies that may arise.

People who use the service were limited in their ability to give specific views but relatives and commissioners told us they were generally happy with the service they received from The Elms and felt that people were safe using the service. The service had systems in place to manage risks to both people and staff. Staff had good awareness of how to keep people safe by reporting concerns promptly through procedures they understood well. Information and guidance was available for them to use if they had any concerns.

People were treated with kindness, dignity and respect. They were involved in decisions about their care as far as they were able and relatives/representatives told us they had been asked for their views on the service. People’s care and support needs were reviewed regularly. The acting manager ensured that up to date information was communicated promptly to staff.

Staff felt well supported by the acting manager and said they were listened to if they raised concerns and action was taken straight away if necessary. We found an open culture in the service and staff were comfortable to approach the acting manager and the assistant manager for advice and guidance.

Staff understood their responsibilities in relation to gaining consent before providing support and care, therefore people’s right to make decisions was protected. New staff received an induction and training in core topics.

The inspection team consisted of one adult social care CQC inspector. On the day of our inspection ten people used the service. We spoke with three people who use the service, three people’s relatives, two care workers, two assistant managers and the registered manager.

The Elms is one of a group of residential homes providing care and support to people within a village environment known as Ravenswood Village. It was run primarily for those of Jewish faith, but people and staff did not have to be Jewish to live or work there. People were supported to practice their faith, and the village celebrated Jewish rituals and festivals. People had the choice of whether they wished to attend the synagogue or follow Jewish rituals.

We observed how staff supported people, and looked at documents including care plans and management reports. We had found areas of non-compliance with the Health and Social Care Act regulations at a previous CQC inspection on 10 September 2013. This was in relation to record keeping and monitoring and assessing the quality of service provision. As part of this inspection we considered if the service was now compliant with these outcomes, and also looked at consent to care, care and welfare of people, and cleanliness and infection control. We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

This is a summary of what we found.

Is the service caring?

We found staff were caring. Relatives described care workers as “absolutely devoted” and “approachable and friendly”. One relative stated “I am thankful X is in The Elms. They can’t do enough for” X.

We observed staff were respectful of people, and included them in all aspects of their care and support. Care workers ensured they supported people as they wished, and promoted people’s independence and wellbeing. People told us they liked the staff.

One care worker told us “The service is full on, vibrant, always on the go. It’s demanding, but it can be a joy to work here”. Another said “We work for the benefit of the people who live here”.

Is the service responsive?

We saw staff were responsive to people’s changing needs, and supported people at the pace they required. People’s care plans reflected their needs and wishes, and care workers updated these to ensure information was current. Care workers sought support from health professionals to meet people’s health needs, such as guidance for diets appropriate for people with swallowing difficulties.

We saw care workers used assistive technology to alert them of people’s location or night activities. They understood actions to follow when this technology did not work to ensure people were not at risk of harm. One care worker told us “It’s all about the residents”.

Is the service safe?

We found the service was safe. One relative told us “overall I’m really thrilled [with the care provided], particularly in regard to cleanliness and care”. One person told us “Staff keep me safe”.

We found people were supported to ensure risks to their health and wellbeing were minimised. Risks were identified and assessed to promote people’s safety without restricting their activities. Care workers followed guidance in people’s care plans to ensure they were supported safely.

The home environment was clean, and staff were aware of actions required to protect people from infections, such as the use of protective clothing and hand hygiene protocols. Confidential records, such information about people and staff, were mostly stored securely. The registered manager was aware of the importance of secure storage and disposal of records, and described the process they followed to meet the required standards. There was a risk-assessed balance between protecting people's records and prompt access for staff to read and update information such as care plans.

Is the service effective?

People were supported effectively to help them understand options and choices, and the consequences of their decisions. One care worker told us “We put them at the centre of decision-making, and offer alternatives”. Staff involved people in all aspects of their care and the running of the home. For example, we saw one person assisted staff with testing the fire alarm during our inspection.

Care workers recognised they could only assist people with their consent, and understood people had a right to make their own decisions, even if staff felt these were poor decisions. One care worker explained “We have to follow what they want. We can’t deny them an opportunity. We have to put our own reservations to one side”.

Is the service well led?

We found the service was well led. One relative told us they could think of “No faults whatsoever”. One care worker told us “The management team are strong”, and another said “There is good management, they always have time to listen, and act appropriately. We get lots of back up here”.

People’s views and feedback were sought, and staff took actions to meet their requests. Relatives told us staff listened to their comments and kept them informed. People were involved in planning their care, support and activities, and agreed house rules to reduce disruptions within the home.

Senior staff and the provider carried out checks and audits to be assured of the quality of the care provided. For example, we saw summaries of accidents and incidents were compiled quarterly to analyse trends for each person. This meant the registered manager was able to identify changes required to promote people’s health and welfare.

People were aware of the complaints process, and were supported to make complaints. The opportunity to discuss concerns was promoted in residents’ meetings.

We spoke to three residents and met with four staff. One resident said that staff were "lovely" and "very nice".

One member of staff described it as a "privilege" to work in the home and to have responsibilities of supporting the residents.

We observed staff interacting with residents in a friendly and courteous way and we observed personal care and support being given generally in a respectful way.

We saw that the environment was clean but the decor was in need of some updating. We saw that people had personalised their rooms. The areas outside the unit were well maintained.

We saw that people were treated as individuals and that there were opportunities for them to spend time off the unit either for leisure or educational purposes, also that staff were available to support them in those activities.

We found that records were not maintained and up to date care plans and risk assessments were not always available in the files.

We also found that there was a lack of quality assurance processes in place to identify and address gaps and omissions.

We saw people making choices over their care and activities. The interactions between staff and people who live at the home were respectful and courteous. We were able to speak with some of the people who live at the home. One person told us they were happy living at the home.

The home was suitably designed and the people living at the home had rooms which were personalised to reflect their interests and choices. One person told us their room was decorated in their favourite colour.

There was a system in place for recruiting staff which sought the views of the people who live at the home. The provider did not take steps to obtain information about any physical or mental health conditions relevant to people's ability to work at the home.

We looked at the system in place for dealing with complaints. We found people were aware of the complaints procedure. When complaints were made they were dealt with in accordance with the home's complaints procedure.

We spoke with three people living at The Elms and observed people’s interactions with staff. People told us that they were happy and the home appeared to have a relaxed atmosphere. We saw that staff supported people in a friendly and respectful way.

We observed the interactions between the staff and people who live at the home. The home appeared to have a relaxed and friendly atmosphere. We saw staff supporting people in a way that was both respectful and friendly.