About the service: The Elms Nursing home is a service where people can receive accommodation, nursing and personal care. The service accommodates up to 19 people who are living with dementia, elderly and frail or who have other health conditions. At the time of our inspection, 16 people were living at the service.

People’s experience of using this service:

Although people received the medicines they needed, we found a lack of good records in relation to people’s medicines. People continued to live in an environment that was not necessarily fit for purpose and was not kept free from infection. Risks to people had been identified, however staff were not always following guidance in people’s care plans to help ensure people were kept free from risk of harm. People were not always cared for by a sufficient number of staff. This meant people did not always get the support they needed. We observed times when people were not always shown respect by staff.

People were cared for by staff who had been recruited through robust processes and received the training and support they required. Where people had accidents and incidents, staff learnt from these and took appropriate action.

Where people lacked capacity, staff were not always following the legal requirements in relation to making decisions on their behalf. We also found that people were not supported to make informed choices about the food they ate. Activities on offer to people had improved.

People’s care plans contained some good information about their needs, however documentation was unwieldy and repetitive making care plans difficult to follow. We found in general people received responsive care, but there was some lack of consistency in relation to this.

The registered manager had started to make some improvements to the service, but progress was slow and audits carried out did not always identify shortfalls. Despite the registered provider telling us after our last inspection what action they planned to take to improve the service we found some of this had not happened.

People received input from healthcare professional involvement and people’s needs were assessed before moving into the service.

During our inspection we found two continued breaches and one new breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also made four recommendations to the registered provider. You can see what action we told the provider to take at the back of the full version of the report. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection: We last inspected The Elms Nursing Home on 18 January 2018 where we rated the service as Requires Improvement. We published the report on 24 March 2018.

Why we inspected: This was a scheduled fully comprehensive inspection carried out in line with our inspection methodology which is based on last inspection rating. We used this inspection to see if the registered provider had actioned the shortfalls we identified during our last visit.

Enforcement: The overall rating for this service is ‘Inadequate’ and the service has therefore been placed in ‘Special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up: If not enough improvement is made within this timeframe so that there is still a rating of ina

The Elms Nursing Home provides accommodation and personal care for up to 19 older people, who may also be living with dementia. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The accommodation is set over one floor with communal lounge and dining areas. On the day of our inspection 17 people were living at the service.

The home did not have 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. There was a new manager (known as the manager) in post who started at the service in November 2017. The manager was about to commence their application to register with CQC.

We last carried out a comprehensive inspection of this service on 17 May 2016 when we rated the service as Good. However, we had received some concerns regarding the service and therefore brought forward this comprehensive inspection to check people were receiving safe care. Although we found on the whole that people received the care they needed, we identified some concerns which told us that people’s care may not always be responsive to their needs. We found records in relation to people were not up to date or accurate which meant that some people could be at risk.

People’s risks had been identified, however it was not always clear that action was taken by staff to satisfy themselves that people were kept free from potential risks. People lived in an environment that was not suitable for their needs or sufficiently hygienic and well maintained.

Medicines management procedures were not always followed in line with best practice and the legal requirements in relation to obtaining people’s consent were not being adhered to. Quality assurance processes in relation to care records and the monitoring of the service being provided were not robust. Although the manager had identified many of the areas that we had concerns in and as such had developed an action plan which they were working to. The manager had only commenced in post in November 2017 so they were still getting to know the service. They told us it may take them a year to achieve what they planned for the service.

The registered provider was not aware of their statutory duties in relation to CQC and as such had not notified us of some significant events. Staff received training to carry out their roles and as such relatives and professionals felt staff were competent. The manager had been undertaking supervisions with staff.

People felt safe living at The Elms Nursing Home and staff were aware of their responsibilities to ensure that if they had any concerns about the way people were being cared for they should raise this. In the event of an emergency people’s care would continue in the least disrupted way possible.

People enjoyed the food that was provided to them and told us they could eat their meals in the place of their choice. People had access to health care professionals as and when needed and when people moved into the home staff assessed their needs in order to help ensure they could provide appropriate care.

People were cared for by staff who were kind, attentive and respectful to them. People and their relatives gave us very positive feedback in relation to staff and the way that they treated them. We observed gentle, caring interactions between staff and people and it was clear staff knew people and their family members well. People did not always have the opportunity to participate in activities that were individualised and meaningful to them. The manager had identified that an additional activities co-ordinat

The Elms Nursing Home is registered to provide accommodation and nursing care for up to nineteen people some of whom may be living with dementia.

The home is located in Redhill and is part of the Whitepost HealthCare Group. On the day of our inspection 16 people lived at the service.

There was a registered manager in place who was present on the day of the inspection.

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 were not always cared for in an environment that was in a good state of repair. We noted bed rail bumpers were worn and could not be cleaned effectively and areas of the home required to be redecorated.

There were enough staff employed in the service to meet people’s needs. People said staff were kind and cared for them well.

People received their medicine as prescribed and medicines were administered and stored safely. Risks had been assessed and managed appropriately to keep people safe. Risk assessments for people were detailed and informative and included measures that had been introduced to reduce the risk of harm.

In the event of an emergency, such as the building being flooded or a fire, there was a service contingency plan which detailed what staff needed to do to protect people and make them safe.

Accidents and incidents were recorded appropriately and evaluated to prevent or minimise reoccurrence.

Staff had knowledge of safeguarding adult’s procedures and what to do if they suspected any type of abuse. Staff recruitment checks had been undertaken before they started work to protect people.

People’s rights were protected under the Mental Capacity Act 2005 (MCA), and the Deprivation of Liberty Safeguards (DoLS). These safeguards protect the rights of people by ensuring that people were consenting to their care. This also ensured that people who were unable to consent to restrictions to their freedom and liberty had DoLS assessment in place that had been authorised by the local authority.

People received care from staff who had received appropriate training to meet people’s needs. The provider ensured all staff were kept up to date with the mandatory training including moving and handling and health and safety.

Staff were supported in their work and said that they had regular supervision with their line manager. This gave staff the opportunity to discuss their performance or any other issues with their manager and these sessions were formally recorded.

Nutritional assessments were carried out when people moved into the home which identified if people had specialist dietary needs. People had access to a range of health care professionals, such as the GP, dietician and chiropodist.

Staff at the service were caring and supportive and treated people with dignity and respect. We saw that care plans were person centred and had involved people whenever possible. Staff knew and understood what was important to the person.

People were supported by staff that were given appropriate information to enable them to respond to people effectively. Where it had been identified that a person’s needs had changed staff were providing the most up to date care.

People who were able could take part in limited activities which they enjoyed. People and relatives told us that they knew what to do if they were unhappy about something. There was a complaints procedure in place for people and relatives to access if they needed to.

Staff said that they felt valued and listened to. Systems were in place to monitor the quality of the service that people received. This included audits and surveys. However audits did not always identify issues relating to the environment and some record keeping.

Services that provi

Our inspection of this care service helped answer our five questions. Is the service safe? Is the service caring? Is the service responsive? Is the service effective? Is the service well led? Below is a summary of what we found. The summary is based on our observations during the inspection, talking to people who used the service, the staff supporting them and from looking at records.

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

Is the service safe?

Systems were in place that ensured people who used the service were kept safe. Staff who supported people were aware of the adult safeguarding procedures in place and their responsibilities for reporting any suspicion of abuse to their manager. We also saw systems were in place that ensured the staff team learnt from events such as accidents, incidents, concerns, whistleblowing, and safeguarding investigations.

When risks were identified risk assessments were put in place to manage the risk effectively without compromising people's independence. For example when a person was at risk of choking an appropriate diet was provided and sensitive support offered to maintain that person's dignity and independence.

Regular health and safety audits ensured the safety and welfare of people who used the service, staff and visitors.

Is the service caring?

People were treated with respect and dignity by the staff. All the people we spoke with said they were contented living in the home but said "there's no place like your own home". They said the staff were very kind and the food was good. We saw several people were nursed in bed and they all looked comfortable and well cared for. We noted that people had a plentiful supply of cold drinks available to them as the weather was very hot and staff ensured they kept hydrated.

Is the service effective?

People's health care needs were assessed and care and treatment was undertaken to meet their individual needs. There was support from other health care professionals and we saw the chiropodist and GP visited during out inspection. A relative told us they were kept informed of changing care needs and they were able to talk with health care professionals about care and treatment and were listened to.

Is the service responsive?

We saw when people's needs changed these were reviewed and care plans were updated to reflect the new need. Guidance for staff on how to meet this need was also updated. We looked at the complaints procedure and saw they were no formal complaints made since our last inspection. We saw that if a complaint had been received there was a system in place which would ensure investigation and action. We saw the manager was quick to respond to a relative's request to call a member of the local clergy to attend to an end of life need, which provided reassurance for the family.

Is the service well led?

The service was well managed by the registered manager who had the skills, qualifications and experience to undertake their role. The service worked well with other professional bodies and authorities which ensured on- going continuing care.

The service has quality assurance systems to asses and monitor the quality of the service provided and to manage improvements effectively.

People told us that they liked the home and that staff were supportive and kind.

A relative of a person who used the service told us that they could visit the home at any time and were always made welcome.

They said that the staff were more than helpful.

People's needs were assessed and care and treatment was delivered in line with individual care plans.

People had access to information about the home before they were admitted.

We observed that people looked comfortable, relaxed and were well groomed.

The activities coordinator showed us some of the activities available and people said that they had enjoyed the recent "Ascot hat parade". Staff told us that they enjoyed working in the home and that they were provided with ample training to enable them to undertake their roles.

We looked at the provider's quality assurance systems and found that there was a wide range of monitoring processes in place.