This inspection took place on 21 August 2018 and was unannounced. The last inspection was in June 2017, where we found five breaches of regulation relating to governance, staffing, consent, person-centred care and premises and equipment. We asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe and well-led to at least good. At this inspection in August 2018, we found improvements had been made and the service was no longer in breach of regulations.

The Elms is a ‘care home’. 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 care home accommodates up to 20 people in one adapted building. At the time of this inspection there were 18 people living in the service, most were older people some of whom were living with dementia.

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.

Improvements had been made to ensure the governance arrangements identified where quality and safety were being compromised. Though further work was necessary to embed new systems and processes, it was clear the provider and registered manager had taken steps to improve and build upon their existing governance arrangements.

People’s medicines were generally managed well by staff who were trained to administer people’s medicines. However, we found that further improvement was needed with the application of creams, documentation, and more robust auditing processes.

There was a new person centred electronic care planning system in place which was replacing paper records. This system was still quite new and not all information had been transferred over. We found some errors in transfer of risks such as choking, and the registered manager took action to ensure these were put onto the system promptly. We advised them to prioritise those people most at risk to ensure safe delivery of care.

Further work was required to ensure that people’s end of life wishes were known. Care records contained only very basic information. However, advance care plans were in the process of being completed.

There was not a dedicated activity co-ordinator working in the service, but staff delivered activities. A schedule of activities had been implemented, but people preferred a less structured approach. Some people we spoke with indicated that at times they felt bored and would like more to do. We have made a recommendation that the service ensures it is meeting people’s individual and specialist needs on a day to day basis.

Staff were seen to be kind and caring towards people, however, our observations and feedback received from people indicated that further work was needed to ensure that the staff and management approach was consistent and people’s dignity was respected.

Staffing levels and deployment of staff had been reviewed and new processes implemented which ensured that staff knew their roles and responsibilities.

Staff took appropriate precautions to ensure people were protected from the risk of acquired infections, and the services’ cleaning regimes were more robust.

Staff had regular supervision and they had been trained to meet people's individual needs effectively. Staff were encouraged to progress in their roles, and higher level qualifications were offered.

The requirements of the Mental Capacity Act 2005 were being met, and staff understood their roles and responsibilities to seek people's consent prior to care and support being provided. However, further improvements in relation to care p

This inspection took place on 6 June 2017, and was unannounced.

The Elms residential care home provides accommodation and personal care for up to 20 people. At the time of this inspection, there were 18 people using the service, some of whom were living with dementia.

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.

During this inspection, we found that the registered provider was in breach of five regulations 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 the report.

People’s health, safety and well-being were at risk because the registered manager and provider had failed to identify where safety was being compromised. Infection prevention and control procedures were ineffective and we found that hygiene in the service was poor. This included in areas where food was prepared. People's individual needs were not met by the adaptation, design or decoration of the service. This could compromise the ability of people living with dementia to move around independently. This constituted a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider and registered manager had failed to recognise potential harm to people using the service. Quality assurance and auditing mechanisms did not identify concerns we found during the inspection. This constituted a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staffing levels were not sufficient in order to meet the needs of people and keep them safe at all times. This constituted a breach of regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were not always protected from social isolation, particularly those people who were cared for in bed due to illness or frailty. The range of activities available were not always appropriate or stimulating for people living with dementia. Care plans did not always hold sufficient detail about people’s life history or social needs. This constituted a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The registered manager had not applied for Deprivation of Liberty Safeguards when people who lacked capacity to consent, had their liberty restricted. Best interests documentation was not always in place where decisions had been made on behalf of people who lacked capacity. This was a breach of regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The dining experience was not conducive to an enjoyable mealtime and opportunity for social interactions, and we have made a recommendation about improving the dining experience for people.

Staff interacted with people in a kind and caring manner. However, we observed that at times people’s dignity was compromised.

Appropriate arrangements were in place to ensure people’s medicines were obtained, stored and administered safely.

People were referred to other health care professionals to maintain their health and well-being.

Procedures were in place which safeguarded the people who used the service from the potential risk of abuse. Staff understood the various types of abuse and knew who to report any concerns to.

Safe recruitment procedures were in place, and staff had undergone recruitment checks before they started work to ensure they were suitable for the role.

This inspection was unannounced and took place on 3 March 2015.

At the last inspection on 21 July 2014, we asked the provider to make improvements because people were at risk due to the lack of detail and guidance to staff within people’s risk assessments. We also found that important events that occurred at the home affecting the welfare, health and safety of people were not reported to us. At this inspection we found that improvements had been made.

The Elms provides care and accommodation for up to 20 older people, some of whom may be living with dementia. On the day of this inspection there were 18 people living at this home.

This service is required to have a registered manager in day to day charge of the home. 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 registered manager in post at this service.

People who lived at the home felt safe. Staff knew about how to safeguard people from abuse and what to do if they suspected abuse was occurring. Risk assessments were in place in respect of people’s care, treatment and daily living.

There were enough staff on duty to meet people’s needs. The home was staffed in accordance with the staff rota that was based on the dependency needs of people. Thorough recruitment practices were in place with plans to involve people in the process in the future.

People were protected by safe processes in place in respect of the storage, administration and recording of medicines. Staff received training and their competence was periodically assessed. However, the medicines trolley wasn’t always locked when unattended during a medicines round.

People were supported by well trained, experienced and knowledgeable staff. Staff were able to attend training that was relevant to their role including nationally recognised qualifications in care.

Staff were due to receive training about the Mental Capacity Act and Deprivation of Liberty Safeguards. Staff understood that some people may on occasion lack the capacity to make decisions for themselves and that they needed to support people to make choices that were in their best interests.

People received food and drink that met their needs. People at risk of malnutrition were referred appropriately to health professionals and were supported to eat well. Meals were fortified as necessary.

People were supported by kind, considerate and compassionate staff. People were encouraged to be as independent as possible and their rights were promoted. Staff provided care and support that was person-centred and individualised.

Care plans gave information and guidance to staff so that they could provide appropriate care and support to people. People were encouraged to be involved in planning and reviewing their care.

Quality monitoring of the service provided was taking place in respect of the environment, records and care, treatment and support of people. Any shortfalls were identified and action taken to improve the service.

Staff felt listened to and were involved in developing the quality of the service. People’s views were sought and acted on. Progress had been made to embed a culture of person-centred care that reflected the needs and aspirations of people living at the home.

The inspection team who carried out this inspection consisted of a pharmacist and two inspectors. The focus of the inspection was to check if improvements had been made to the previous non-compliance we identified. During the inspection, the team worked together to answer the five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, relatives and staff told us, what we observed and the records we looked at.

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

This is a summary of what we found:

Is the service safe?

People said that they liked living at The Elms Residential Care Home. They told us that they occasionally had to wait for help because the staff were busy. Improvements had been made to ensure that the records held were complete and up to date. Improvements had also been made to ensure there were sufficient numbers of staff on duty to meet the needs of the people living at the home. We saw that call-bells were answered when they were rung.

Staff personnel records contained the information required by the Health and Social Care Act 2008 and showed that all of the staff employed to work at the home were suitable and had the skills and experience needed to support people living at the service.

There was a process in place in relation to the Mental Capacity Act (2005) and Deprivation of Liberty Safeguarding (DoLS). Policies and procedures were being written by the provider. There had been no reason to submit a DoLS application. The manager had been trained and knew when a DoLS application was needed and how to submit it.

Is the service effective?

People’s health and care needs were assessed with them or their family member. Specialist dietary, mobility and equipment needs had been identified in care plans when required. Relatives told us their family member received the care and attention they required in a way that met their needs. Through our observations and speaking with staff we noted that the staff understood the care and support needs of each person. One person told us. “This is a nice home and the staff will do anything to help you.” Staff, had received some training and were completing further training to ensure that they were trained to meet the needs of people living at the home.

Is the service caring?

People were supported by staff who used a kind and attentive approach. We saw that the staff were patient and encouraged people to be as independent as possible. People told us that the staff were sometimes busy but did not rush them. Our observations confirmed this. A visitor told us. “I am happy with the care given to my family member. The members of staff are polite and respectful.”

Is the service responsive?

Care and risk assessments had been completed but some lacked detail that told staff how to provide people’s care and support safely. A compliance action has been set for this and the provider must tell us how they plan to improve. The care and support provided was adjusted to meet the needs of each person. Any change in care and support was recorded in the person’s plans of care. A record was held of people’s preferences, interests and diverse needs. Relatives told us that staff members consulted their family member and encouraged them to make their own decisions. People had access to some activities but two people told us they were sometimes bored.

Is the service well led?

Staff spoken with had an understanding of the ethos of the home and quality assurance processes were in place. Relatives told us that they were asked for their feedback on the service their family member received. Visitors and staff said that they had felt listened to when they had made a suggestion or raised their concerns. We had not been informed when adverse events, such as a person having a fall, happened in the home. A compliance action has been set for this and the provider must tell us how they plan to improve. People told us that the new manager had made many improvements and was approachable.

We conducted this inspection to follow up on our findings in March 2014 when we identified and raised concerns in relation to the way people’s medicines were being managed. In addition, we recently received concerns that members of staff were not always following safe procedures when giving people their medication. We were also advised that some medicines which had been recorded as being given to people, had been found in their rooms. This indicated that they may not have been taken by them

A pharmacy inspector carried out this inspection. The focus of the inspection was to answer one key question; is the management of medication safe?

In order to assess if people’s medicines were being managed safely we conducted an audit of medicines and the records relating to them. We also checked if medicines were being stored securely and observed a staff member giving people their medication.

We were able to account for medicines and we noted improvements in record-keeping. The supporting information available for staff to refer to when administering medicines had also improved and medicines were being stored securely.

However, we found some lose tablets in two containers being stored within a cabinet. The manager told us that these had been found by staff under one person's table. This indicated that the person may not have not taken them. We also observed some unsafe practice when a staff member was giving people their medication. The manager confirmed that not all members of staff had been observed and assessed as being competent to give people their medication. We were therefore not assured that medicines were being given to people safely.

During a previous inspection, we found that the provider was failing to meet a number of standards of quality and safety. We therefore returned on the 10 December 2013 to see if improvements had been made. We found that overall, improvements had been made but that some standards were still not being fully met.

During this inspection we spoke with nine people who used the service, two relatives, seven staff and the acting manager.

We arrived at the service at 5.30am. We found that some people were up at this time but they confirmed that they were happy to be up early in the morning.

People told us that they were happy with the care they received. We saw that staff were attentive to people’s needs and treated them with respect.

People’s care needs and risks to their safety had been assessed. However, we could not be assured that some people’s risk of malnutrition was being managed effectively.

The service was being deep cleaned on the day of our inspection. The provider had plans in place to clean the service following a concern that had been raised in relation to infection control. We saw staff following good infection control practices.

There were enough staff to meet people’s needs. However, the provider had not followed the required recruitment checks when employing staff to the service and there were some gaps in some staff’s training.

The quality of the service being provided was not being effectively monitored at the time of our inspection. However, the provider had a plan in place to implement a comprehensive quality monitoring programme. This commenced shortly after our inspection.

Records containing confidential information were being stored securely. However, some records were not being completed or were inaccurate.

During the inspection we spoke with three people who used the service and with two members of staff.

The People who used the service told us that the support and care they received was good. One person we spoke with told us that the service was, "Really excellent." They went on to say that, "The staff here are brilliant and show a lot of respect for all the people in the home." Another person we spoke with told us that the staff were, "Very appropriate, friendly and knowledgeable."

People were happy with the facilities and told us they were looked after well. One person said, "Everything is fine, I have nothing to complain about." Another person we spoke with told us that they were well looked after. They said, "The food is good, and they (the staff) will always do something else if you don't like it."

The service provided a safe and comfortable environment for people who used the service, with a very 'homely' feel.

New staff all received the necessary training when they joined the service, but this was not followed up with training updates and refresher courses. This meant that existing staff had not received training to ensure their knowledge and practice was up to date.

People we spoke with told us that they had chosen to live in The Elms and that they had visited the home before deciding to move in.

People we spoke with told us that they were very happy living in The Elms and that the staff were very kind and caring.

One person told us: "I love it here. The staff are very good and give me as much support as I need."

Three people told us that they always had things to do and that they were able to spend their time as they wanted to. One person said: "I never get bored, there's always so much going on around."

Three people told us that they felt safe and well looked after in The Elms and one person said they were quite happy speaking to any of the staff or the manager if they had any concerns.

One person told us: "The staff do listen when you ask them or tell them anything."

Following our inspection in December 2013, we found that the provider was not meeting some of the regulations relating to quality and safety. We therefore returned to see if improvements had been made.

During this inspection, we spoke with eight people who used the service, two staff and the manager who had been in post for five weeks at the time of the inspection. The registered manager shown on this report, Mrs Susan Burridge, no longer works at the service but will remain on our records until we receive an application to de-register her.

People told us that they were happy with the care they received. One person told us “I am very well looked after.” Another person told us, “I am happy living here, we get plenty of food to eat.” A further person said, “It’s nice here.” However, the four people that we discussed activities with told us that there was a lack things for them to do during the day to keep them occupied.

People’s needs had been assessed and care was being delivered to keep them safe and to protect them from harm.

Medicines continued not to be managed safely. We therefore could not be assured that people were receiving their medication as intended by the prescriber.

The required checks on new staff employed by the service were being completed.

The quality of the service was being monitored regularly so that improvements could be made.

People’s records were kept securely to maintain confidentiality. However, some records had not been completed or did not accurately reflect the care that was being provided. This meant that there was a risk that the staff could provide unsafe or inappropriate care.