Archived: The Elms

The Elms is a residential care home providing accommodation and personal care for up to 28 people aged 65 and over at the time of the inspection. It accommodates people in one adapted premises with shared facilities. The service can support up to 37 people.

People’s experience of using this service and what we found

Staff did not consistently apply good infection control practices and some areas of the home and equipment were not clean. Not all agency staff had received an induction before they started working at the service and there were times when staff were unavailable to support people. Staff did not always keep up to date records. The provider’s systems for ensuring the safety and quality of the home fell short in these areas.

People told us they felt safe and staff were knowledgeable about risks to people and followed risk assessments, which they regularly reviewed.

People received their medicines appropriately and were protected from the risk of abuse. There were systems and processes in place to learn from safety-related incidents.

There was a warm atmosphere in the home and staff worked closely with other healthcare professionals to meet people’s needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 24 October 2018). The service remains rated requires improvement. This service has been rated requires improvement or inadequate for the last five consecutive inspections.

Why we inspected

We received concerns in relation to safeguarding. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has remained the same. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Elms on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to infection prevention and control and governance at this inspection.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information, we may inspect sooner.

The Elms is a residential care home providing personal care to 33 people aged 65 and over at the time of the inspection. The service can support up to 37 people.

People’s experience of using this service and what we found

Some areas of the service required more stringent domestic schedules to ensure they were cleaned in a consistent way. The quality assurance system had improved, although the registered manager was to ensure greater oversight of the domestic issues. A redecoration and refurbishment plan of specific areas was underway.

People were protected from the risk of harm and abuse. Staff understood safeguarding procedures and reported concerns straight away. People received their medicines as prescribed although there had been a concern that one person’s pain relief could have been administered more frequently.

There was enough staff on duty to meet people’s needs. Staff completed a range of training and had supervision and support to enable them to feel confident when completing care tasks.

People had assessments before admission to ensure their needs could be met and ongoing risk assessments in order to minimise incidents affecting their wellbeing occurring. Each person had a care plan, which guided staff in how to care for them. People’s health and nutritional needs were planned for and met. Any concerns were raised with health professionals.

Staff supported people in a kind, friendly and person-centred way. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published December 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection, enough improvement had not been made and the provider was still in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained the same, requires improvement. This is based on the findings at this inspection.

We found improvements in some areas but there was a breach of legal requirements in relation to hygiene and domestic practices in Safe. You can see what action we have asked the provider to take at the end of this full report. The provider took immediate steps to address hygiene concerns and put in place plans to speed up refurbishment.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Elms on our website at www.cqc.org.uk.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Elms is a residential care home providing personal care to 30 people aged 65 and over at the time of the inspection. The service can support up to 37 people, some of whom may be living with dementia.

People’s experience of using this service and what we found

There was a concern the initial assessment for two people was not as thorough as it should be, and they had been admitted to the home when they may have needed a more specialist service. Some people had not consistently received their medicines as prescribed, which had the potential to impact on their treatment.

There was a new manager in post, who had started to implement the provider’s quality monitoring system. However, for several months the system had not been wholly effective in identifying the issues we found during the inspection or shortfalls had not been addressed in a timely way. When reviewing incidents that had occurred in the service before the new manager took up their post, we found several had not been reported to the Care Quality Commission (CQC). It is important we know about these incidents, so we can check what action has been taken.

Staff received training and induction. There were gaps in staff supervision and appraisal. However, these had been identified and we have been assured an action plan will address the shortfalls. We have made a recommendation about keeping the supervision and appraisal under review to ensure staff receive support and guidance.

The provider had been quick to respond to a safeguarding incident when they became aware of it and took appropriate action. Staff had received training in how to safeguard people from abuse and knew how to report incidents.

The provider had a safe system of staff recruitment. There had been a need for the use of agency staff recently, which, although not an ideal situation, had ensured there were always enough staff on duty.

People’s health and nutritional needs were met. Staff ensured people received care and treatment from health professionals when required. People who used the service liked the meals provided.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff ensured relatives were welcome to visit at any time and provided activities daily, so people could choose to participate if they wished. Staff were described as friendly, kind and caring.

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

Rating at last inspection

The last rating for this service was requires improvement (published 17 May 2018).

At this inspection, enough improvement had not been made and the provider was now in breach of regulations. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches at this inspection in relation to assessing people’s needs in a thorough way, management of medicines, monitoring and improving quality, and ensuring CQC is notified of incidents affecting people’s welfare. Please see the action we have told the provider to take at the end of this report.

Since the last inspection we recognised that the provider had failed to notify us of incidents that affected the safety and welfare of people. This was a breach of regulation and we issued a fixed penalty notice. The provider accepted a fixed penalty and paid this in full.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Elms is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The Elms supports up to 37 older people, some of whom may be living with dementia. Communal rooms consist of a sitting room with a small quiet area at one end, a further smaller sitting room and a dining room. There is also a small seated area in the entrance and another in a walkthrough area near patio doors which leads out to a courtyard. Bedrooms, bathrooms and toilets are located over three floors accessed by a passenger lift.

The service had a registered manager. A registered manager is a person who has registered with the CQC 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.

Risk was identified and managed more effectively, which meant people who used the service were protected from potential and actual harm. Staff received safeguarding training and knew how to protect people from the risk of abuse; they described what they would do if they witnessed abuse or poor practice. The provider used local safeguarding policies and procedures and contacted the safeguarding team for advice when required.

Medicines were managed safely and people received them as prescribed. Medication was stored appropriately and stock was managed more effectively, which reduced unnecessary waste. There was a clear system for returning unused medicines.

People’s health and nutritional needs were met. People at risk of deteriorating health or poor nutrition were monitored and staff liaised with community healthcare professionals for advice and treatment.

Staff were responsive to people’s needs and supported them in an individual way. They knew people very well and could describe in detail the support they required. People and their relatives had only positive comments about the staff approach and described it as caring and kindly. We observed staff were friendly and attentive to people and their relatives.

People were supported 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 practice.

There was sufficient staff deployed in the service. The provider had recruited more care and domestic staff and reorganised the shift pattern to suit the needs of the service. A deputy manager had been recruited, which had enhanced the support available to the staff team. A new activity coordinator ensured activities were higher on the agenda and people received social stimulation.

Staff received training, supervision and appraisal to ensure they felt confident and were skilled when supporting people who used the service.

The quality monitoring system had improved and audits were completed in a more robust way. This ensured any areas identified for improvement were addressed in a timely way. Visits were completed by senior management to ensure they had oversight of the service. A recent survey had been completed and areas identified as requiring improvement had been noted and addressed. Meetings were held, which enabled people who used the service, their relatives and staff the opportunity to express their views.

The provider had a complaints procedure. People felt able to complain and were confident the registered manager would address them. They had noticed the registered manager was more visible and did not remain in their office all day.

The Elms is registered to provide care and accommodation for a maximum of 37 older people, some of whom may be living with dementia. Communal rooms consist of a sitting room with a small quiet area at one end, a further smaller sitting room and a dining room. There is also a small seated area in the entrance and another in a walkthrough area near patio doors which leads out to a courtyard. The service has a large lawn at the front of the house and a car park. Bedrooms, bathrooms and toilets are located over three floors accessed by a passenger lift. Most bedrooms are for single occupancy but there are also some bedrooms for shared use. The service has good access to local facilities and amenities. At the time of the inspection, there were 34 people living in the service. We were told two people also attended the service for day care.

The service had 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.

At the last inspection on 27 and 28 April 2017, we judged the service as ’Requires Improvement’. This was because we had concerns about recruitment processes potentially placing people who used the service at risk. There were also concerns that we had not received notifications of incidents which affected the safety and welfare of people who used the service.

Prior to this inspection, we received information of concern regarding the safety of medicines management. There were some safeguarding investigations underway from January 2017 which related to potential shortfalls in the delivery of care; these were still on-going and being undertaken by the local authority. There were also some concerns about the number of accidents and incidents which occurred in the service. We decided to complete a focussed inspection to look at medicines management and to see how risk was assessed. Due to the number of concerns and level of risk found during the inspection, we changed the focussed inspection to a full comprehensive inspection.

The concerns identified during the inspection resulted in us finding the provider in breach of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches included, management of the service, providing person-centred care, not maintaining privacy and dignity, the management of medicines, cleanliness and infection control, identifying and managing risk, good governance and staffing.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’ and the provider must take action to improve and sustain the improvements. 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. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the registered provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.

We found concerns with how the service was managed and governed. Audits had been completed but these had not been effective in identifying shortfalls and ensuring that lessons could be learned and practice improved. There was also a lack of analysis regarding accidents and incidents and improvements were needed in the investigation reports requested by the local authority.

There was a lack of robust risk management; areas of risk had not been identified and there was a lack of systems to check on-going concerns. This related to the environment, equipment used in the service and people’s individual risk assessments. This had placed people at risk of potential or actual harm.

We found infection prevention and control had not been managed appropriately. Areas of the service and some equipment were not in a hygienic state. This placed people at risk of infections.

There were concerns with the safe and proper management of medicines. This had led to some people not receiving their medicines as prescribed and there was a lack of guidance for staff when administering ’when required’ medicines. There was also a poor system of stock control that led to large amounts of wastage.

We found there was insufficient staff on duty during the day and not enough domestic staff at weekends, although recruitment was underway for this. The shortages of staff had impacted on support provided to people at meal times and observation of communal areas at specific times of the day to prevent accidents and distract people whose behaviour could be challenging. It had also resulted in a lack of staff attention to people’s personal belongings; this in turn had impacted on people’s dignity.

People who used the service had assessments and care plans but these did not always contain the most up to date information about their needs. This meant care could be overlooked and placed people at risk of receiving care that did not meet their needs.

People’s health care needs were met and they had access to community health care professionals who visited the service to provide treatment and advice.

We found people’s nutritional needs were met although one person did require more active support from staff. People liked the meals provided and there was plenty to eat and drink.

There were activities provided in-house and monthly outings were arranged. Some people benefitted from the activities more than others and we have made a recommendation about sourcing specific activities for people living with dementia and having a designated member of staff.

We found staff had access to a range of training and they said they felt confident when supporting people. Supervision and support arrangements were in place, although staff told us this had not been as good as expected recently.

The provider had a complaints procedure and people felt able to raise concerns. Complaints were logged by the registered manager.

There had been improvements in the documentation of staff recruitment. The new staff recruitment record we looked at had full employment checks in place.

Following the inspection, we received an action plan formulated by the regional manager which showed us that all the shortfalls we identified during the inspection had been taken seriously by the provider. We will continue to monitor the service and complete a further inspection to check out progress with the action plan.

This inspection took place on 27 and 28 April 2017 and was unannounced. The service was last inspected April 2015 and was found to be compliant with the regulations inspected at that time.

At the time of the inspection 37 people were living at the service.

There was a registered manager in post. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Processes had not been followed to ensure the safety of the people who used the service and to make sure they were not exposed to staff who may pose a risk to them. You can see what action we have told the provider to take and the end of this report.

People were cared for by staff who understood the importance of protecting them from harm and who’d had training in how to identify and report abuse. Staff were provided in enough numbers to ensure the needs of the people who used the service were met. The service was clean and tidy and there were no mal-odours. People’s medicines were handled and administered safely.

The food provided was wholesome and nutritious. People’s food and fluid intake was monitored so they had a healthy well-balanced diet, staff made referrals to other health care professionals if people experienced any dietary issues, for example, the risk of choking or a reduction in their appetites. Systems were in pace to protect people who needed support making informed decisions. Meeting had been held to ensure any decisions made on their behalf would be in their best interest. Staff had received training which equipped them to meet the needs of the people who used the service; they were also provided with opportunities to gain further qualifications and experience.

People were supported by staff who were kind, caring and understood their needs. The interaction between staff and people who used the service was open and respectful. People had been involved with the formulation of their care plans and had been involved in meetings about their ongoing care needs.

A choice of activities was provided for people to participate in if they wished. This included in house activities as well as visits to the local community and the use of local facilities. The registered provider had a complaints procedure which was displayed around the service and people could easily access. All complaints were investigated to the complainant’s satisfaction. The complaint procedure signposted complainants to other agencies if they were not happy with the way their complaint had been investigated, for example, the local government ombudsman.

The registered manager was open and approachable and people found them helpful. Staff found the registered manager approachable and felt confident they could go to them for advice and guidance. People who used the service and other stakeholders were asked for their views about how the service was run. Any issues were addressed by the use of time limited action plans. We have written to the registered provider reminding them of their duty to send notifications to the CQC in a timely way concerning any event or incident which happens at the service which affects the wellbeing of the people who use the service.

Information was available for staff to follow which ensured people received the right level of care to meet their needs. Staff were able to describe people's needs and how to maintain people's dignity and rights.

The home was clean, tidy and was designed to meet the needs of the people who used the service. People told us they were happy with their rooms. One person said 'I have a lovely room, it looks out onto the garden and the staff keep it nice and clean for me.'

There were enough staff on duty both during the day and night to meet people's needs. People who used the service told us, 'The girls are always there when I need them' and 'No, I never feel rushed and there are always plenty of carers around.'

Records were fit for purpose and stored securely.

We found that people were provided with a varied and nutritional diet. People told us the food was excellent and they had plenty of choice. Comments included, 'The food is always good here' and 'There's always plenty of choice.'

We found that people's medication was administered and stored safely and staff had received medication training.

We also found that staff had received training about meeting the needs of older people and how to keep people safe from harm.

We found that people could make complaints and these were acted on and resolved where possible to the person's satisfaction. People told us they would approach the manager or the care staff if they had any concerns.