The inspection was unannounced and took place on 5,10,11 January 2017

Three Elms is a care home which provides accommodation and personal care for up to 56 older

people. The premises comprise a three story building with accommodation grouped into two units, one on the ground floor which can accommodate up to 41 people and a unit on the first floor which can accommodate up to15 people. This unit is specifically utilised for people who are living with dementia. The premises merge inconspicuously into a residential area in Penketh which is on the border of Warrington and Widnes Cheshire. There were 15 people living in the upstairs unit and 36 people living on the residential care unit on the ground floor on the day of our visit.

At the time of the inspection the current manager who had been in post for three months was awaiting her interview with the Care Quality Commission to become the registered manager of Three Elms. Since the inspection this process has been successfully completed. 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.

CQC is required by law to monitor the operation of the Mental Capacity Act, 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves. At the time of the inspection the service had submitted seventeen DoLS applications for people living in the home, seven of which had been authorised by the local authority.

People were at the heart of the service. Staff understood what was important to the people who lived at Three Elms and worked closely with them and, where appropriate, their families to ensure each person had a meaningful and enjoyable life. People played an active part in the running and development of the home.

There was a warm and homely atmosphere and staff cared for people with kindness and genuine interest.

Innovative approaches such as wallpaper of past true life scenes such as “Bobby on a bike” and “The public bar” enhanced people’s quality of life and provided therapeutic benefit to people living with dementia or mental illness.

People were supported to maintain personal interests and hobbies.

The provider had updated the quality monitoring systems and regularly assessed and monitored the quality of care to ensure national and local standards were met and maintained.

People were closely involved in planning and reviewing their care and staff showed knowledge and understanding of the issues involved in supporting people who had lost capacity to make some decisions.

The manager demonstrated an open management style and staff told us she was making a good impact within the home.

We found that although there was a comprehensive training programme it had not been fully embedded into practice and therefore not all staff had received updated training to undertake their roles. Staff told us that they were supported and received some training that provided them with the knowledge and skills to meet people’s needs. Training records identified that the manager and home administrator had identified training shortfalls and had arranged for updated training to be cascaded to all staff with immediate effect.

People and their representatives could voice their opinions and views and knew they would be listened to and acted upon as appropriate.

Staff were trained and knowledgeable in end of life care and support and provided a locally produced leaflet called Coping with Dying, which offered valuable information and words of comfort for both people who use the service and their relatives

This inspection took place on the 26 November 2014. The inspection was unannounced

At the last inspection of Three Elms took place on the 10 July 2014 we had identified breaches of regulations relating to consent to care and treatment, requirements relating to workers, assessing and monitoring the quality of service provision, care and welfare, notification of other incidents and records. Following this the provider sent us an action plan telling us about the improvements they intended to make. During this inspection we looked at whether or not those improvements had been made.

The home had a manager in post who had applied to be registered with CQC.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.

Three Elms is a care home which provides accommodation and personal care for up to 60 older people. There is a unit on the first floor specifically for people living with dementia. There were 8 people living in this unit and 22 people living on the residential care unit on the ground floor on the day of our visit. The home is situated in the Penketh area of Warrington and is close to the local shops and other community facilities.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The Deprivation of Liberty Safeguards (DoLS) are part of the Mental Capacity Act 2005. They aim to make sure that people in care homes, hospitals and supported living are looked after in a way that does not inappropriately restrict their freedom. We saw information that best interest meetings had taken place where people lacked capacity to make decisions for themselves. However, a number of staff still required training in topics such as the Mental Capacity Act and DoLS and dementia care. We have made a recommendation that this training is completed as soon as possible and will be following this up with the registered provider.

We found that other areas with regard to the recording of consent to care and treatment had been improved since our last visit. For example, there were completed documents in the care files which people had signed to state that they had given consent to be photographed and for care to be given. Risk assessments for the use of bedrails had been signed by the people living at the home. We saw that staff gained consent before supporting people with their needs. For example explaining to the person that they were going to assist them out of their chair and asking if that was acceptable before moving them.

We found care plans to be improved and were detailed and focused on the individual person. They contained guidance to enable staff to know how to meet people’s needs and how they wished to be supported. Staff had a good understanding and knowledge of resident`s individual care needs.

People, relatives and staff said there were enough staff on duty each day to meet people’s needs. We observed how staff spoke and interacted with people and found that they were supported with dignity and respect.

We saw that the menus were pictorial which made the choice of food easier for people who may not be able to understand the written menu. People said that food was good and plentiful and they had plenty of choice.

We observed that the home had a complaints procedure and complaints that had been made were recorded with actions taken. This showed us that concerns could be raised and that the manager is open to resolving any issues raised.

Staff recruitment had improved so that people were sure that staff employed were suitable to work with vulnerable people. Appropriate pre-employment checks were being carried out and application forms were more robust to enable the management of the home to have adequate information before employing staff.

Audits at the home were improved as action plans were now in place when shortfalls were found. This meant that improvements could be made and an audit trail could be followed to ensure all actions were met.

The home had been subject to monitoring visits by Warrington Borough Council following safeguarding issues reported by the home and from whistle blowing concerns reported to the Care Quality Commission.

Regular meetings have been held with the provider and all agencies involved and a decision was made by Warrington Borough Council to place an embargo on the home [not allowed to admit new residents]. The council will continue to monitor the home for improvements before this restriction will be lifted. All parties involved believe that it is crucial so that improvements can be made.

Workers from Warrington Borough Council with particular input from the contract monitoring team have been supporting the home throughout this process and they are currently in the process of providing training for staff members.

Notwithstanding the above 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 safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

Below is a summary of what we found. The summary is based on our observations, speaking with people using the service, their relatives; the staff supporting them and from looking at records.

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

Is the service safe?

There were not appropriate procedures in place should anyone need to be subject to a Deprivation of Liberty Safeguard (DoLS) application or plan. DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests. The home has an interim manager who was in the process of completing Mental Capacity Act assessments for all of the people living at the home following a visit and advice from Warrington Borough Council. Staff were receiving updated training to more fully understand DoLS and how it applied to people living at the home.

During our inspection, we looked at a sample of four staff recruitment records. We found that the safety and welfare of people using this service had been compromised because the provider had not followed safe recruitment practices.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the recruitment of staff.

Is the service effective?

During our inspection we looked at care plans for people living at the home.

Care plans looked at did not fully identify choice and consent for people living at Three Elms. Some people living at the home were unable to make choices about their care and treatment. We were told that staff always gained consent, but no consent forms were available in the documentation to confirm this.

We found that care plans did not reflect individual care for each person living at the home and that they would benefit from further development to make them more person centred and reflect the person's full range of skills and abilities.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to keeping accurate records and appropriate information in relation to the care and treatment provided to each person living in the home.

A Whistle Blower had raised concerns that the staffing numbers at the home were inadequate.

The staffing rotas we looked at and our observations during the visit demonstrated that there were sufficient numbers of staff on duty to meet the needs of the people living at the home on the day of our inspection.

Is the service caring?

We saw that staff interacted well with the people who lived at the home. The atmosphere in the home felt relaxed and sociable. During our inspection we found that the people living at Three Elms looked well cared for and were dressed appropriately for the weather on the day. People were clean and tidy and their hair had been brushed or combed. A hairdresser visited the home on a regular basis.

Staff spoken with were knowledgeable about the people they cared for. We could see that they enjoyed good relationships with the people who lived at the home and that they had sufficient time to meet their needs without hurrying.

People spoken with who were able to state their preferences said “Staff treat me well” , “I am happy and contented, I have no problems” and “staff are good”.

However, where people did not have the capacity to make their views known, we saw that potentially inappropriate care interventions were sometimes carried out at unsuitable times.

Is the service responsive?

We looked at a care file for a person living at the home and it was recorded in the daily record sheet by the night staff on duty that they were given a bed bath at 4 o clock in the morning on at least 7 occasions from 28 June to 7 July inclusive. This person had a diagnosis of dementia and was unable to communicate their choices.

This was discussed with both area managers who were present at the home at the time of our visit. They said that this had been raised with staff on night duty and felt that this practice had stopped. This practice had also been reported by social service monitoring officers following their visit to the home in May. There was lack of evidence regarding any appropriate actions taken to address this practice and it was recorded in care plans that this was continuing up to the time of our visit.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to identifying and addressing poor care practices.

It was unclear from some records how current the information for staff was because they were undated and unsigned. Changes in people’s abilities had not always been fully documented or assessed which meant there was a risk that the care provided would not fully meet people’s needs.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to keeping accurate records and appropriate information in relation to the care and treatment provided to each person living in the home.

Is the service well led?

We looked at quality audits that had been completed at the home.

Audits had been completed but there were no action plans to address issues of concerns that had been raised. For example an audit had been completed in May regarding medication by a manager from another home. The score on the audit form was 58% however there was no action plan in place to address concerns raised so that the home could act upon this.

We attended a meeting chaired by Warrington Borough Council’s safeguarding team and it came to our attention that not all reports of alleged abuse had been reported to the Care Quality Commission (CQC).

When we visited the home we asked the area managers and interim manager if they had copies of the notifications sent to CQC. They were unable to produce any.

Staff spoken with had mixed views of the home. Some were positive with regard to changes that needed to be made to improve the standards at the home. Comments such as “I am trying to work together with the management and they have my full support” ” the care plans need to be better and need to be written by the staff on the floor as we know the people best ” and “staff need to accept change. “

Some staff were negative about the management and leadership of the service and felt the management were not listening to them and things should not be changed.

People were able to express their views and they were involved where possible, in making decisions about their care and support. People were seen to be supported by staff to make choices about where they spent their day. One person said “one of the girls has just done my nails , I wanted pink nail polish, its nice isn’t it” Another resident was having her hair permed in the hairdressing room; she was very happy saying “I’m having a perm today; I have my hair done regularly”.

In the dining room there was a large menu board with pictures of the breakfast available, there was seven choices. At lunch time the board changed with pictures of five lunch choices.

We spoke with a number of residents who said “we had a lovely day yesterday in the garden, we had strawberries and ice cream, music a singsong and a little dance with the girls“. One gentleman went with the homes handyman to help him with his chores ,the handyman told us “he always comes along and gives me a hand.“

All staff we spoke with loved their jobs and felt well equipped with training and support to carry their tasks out to a high standard.

A relative spoken with shared her satisfaction with the home and staff “if ever I have any problems I just talk to Linda (care home manager) and its resolved immediately”, Another relative said “staff are so approachable, nothing is too much trouble”.

We spoke with five people who used the service who said they were happy with the care and support provided and they were looked after. They told us that staff respected their rights, their privacy and their dignity. All five people we spoke with said they felt safe. One person said "they just know what I need, they are angels". People told us that they liked their room and that they enjoyed the food and that staff were polite. They said they had choice and were involved in the daily activities.

We spoke with four family members who regularly visit the service. One person told us “I visited the home twice before my relative came here and I am very involved and am always consulted.”

We also looked at a selection of care records. These contained up to date information regarding the needs and wishes of individuals and the staff received the training and support they needed in order to provide safe and effective care for people using the service.

We found that systems were in place to monitor the quality of the service provided. We saw evidence to demonstrate that people were regularly consulted about all aspects of the care and facilities provided at the home.

People spoken with said that they liked living at the home and that they felt safe there. They said that staff are very good and kind and “the staff are always here to help.”

Staff spoken with said that they received regular training and supervision and felt that they were provided with the training they needed to do their jobs.