Elmcroft Care Home

Elmcroft Care Home is a residential care home providing personal and nursing care for up to 54 people. The service primarily provides support to older people and people with dementia. It is also registered to provide support to people with a physical disability, people with a learning disability and autistic people and younger adults. At the time of our inspection there were 42 people using the service.

The care home is in a rural location and has two separate units, called Blythe and GNU.

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

Feedback from people and families was negative in relation to poor management. They gave us examples where people’s individual needs were not met. They also told us some staff provided good care and recently there had been some improvements to the management of the service.

There had been significant management changes since our last inspection, and a new manager had just joined the service. Although the provider had detailed improvement plans and quality audits in place, these had not always been effective or implemented in a timely manner to ensure people received good quality care.

Morale among some staff was low. Senior staff did not always know what was happening across the service and did not communicate or organise staff effectively. Staffing were recruited safely, however improvements were needed in the oversight of agency staff. A revised timetable for staff training was helping ensure staff had the skills to support people safely and in line with their needs.

People did not consistently have a good quality of life. Staff did not always understand and meet people’s needs in a person-centred manner, including around communication and end of life care.

Concerns about people’s safety and complaints were not always managed well. The provider had focused on improving safety and practice around medicine management, risk assessment and care planning was improving. Maintenance and refurbishment works were helping minimise the risk of infection.

Staff did not consistently support people to have maximum choice and control of their lives and to support them in the least restrictive way possible and in their best interests. The policies and systems in the service were in place to support this practice but were not applied effectively.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

The provider did not demonstrate an understanding of Right support, right care, right culture.

Right Support:

Staff and managers did not consistently support people to have a fulfilling and meaningful everyday life.

Right Care:

People’s care, treatment and support plans were being amended to reflect their range of needs.

Right Culture:

The values, attitudes and behaviours of the management and staff did not demonstrate a consistently caring and open culture.

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 good (published 5 May 2019).

At our last inspection we recommended the service looks at good practice guidance and environments for people with dementia. At this inspection we found the provider had invested in this area however there was still room to improve the care and environment for people with dementia.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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 COVID-19 and other infection outbreaks effectively.

We received concerns in relation to poor governance, safety and lack of person-centred care. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

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

Enforcement

We have identified breaches in relation to poor governance and lack of person-centred care at this inspection.

Please see the action we have told the provider to take at the end of this report.

We made a recommendation about Right support, right care, right culture.

Follow up

After the inspection we met with the provider to discuss how they will make changes to ensure they improve their rating to at least good. We will also request an action plan from the provider. We will work with the local authority and health professionals to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Elmcroft Care Home provides accommodation, personal care and nursing care for up to 54 people. The service is split across two units, both of which support people who may have nursing and dementia related needs. At the time of the inspection, 40 people were living at the service.

People’s experience of using this service:

The service kept people safe from harm. Staff understood their responsibilities to protect people from harm and were confident about how to raise concerns in line with the provider's safeguarding and whistleblowing policies.

Risks to people's daily lives had been assessed and measures were in place to prevent avoidable harm and ensure people's freedom was supported and respected.

The service had a process in place for recording, monitoring and analysing accidents and incidents and action had been taken to mitigate the risk of reoccurrence.

Recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work.

Staff were well-trained and worked together as an effective team. Records confirmed staff had access to regular supervision sessions and received annual appraisals.

New members of staff were introduced to the service through an induction programme to ensure that they had acquired the necessary skills to care for people.

Staff supported people to maintain a healthy diet and to access drinks and snacks throughout the day.

The overall environment was not well adapted to people living with dementia or those with sight impairments. The provider had an on-going improvement plan in progress to address this. We made a recommendation that the service looks at good practice guidance and environments for people with dementia.

People were supported to make choices and no unnecessarily restrictive practices were in place.

People received individualised care and support from staff who were kind and patient. They knew people well and understood their choices, likes and dislikes and were committed to ensuring people received good quality care.

Staff felt well supported and had confidence in the management team’s ability to promptly deal with issues raised.

Rating at last inspection: Requires improvement (published 20 January 2018).

Why we inspected: This was a planned inspection based on the rating at the last inspection. At the last inspection on, 19 October 2017, we found staff competency assessments were not sufficiently robust and staff were not consistently skilled when supporting people with dementia or complex mental health needs. The provider and registered manager had not been pro-active in addressing concerns in a timely manner and the lack of a deputy manager and clinical lead had impacted negatively on the service.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the quality of the service. At this inspection, we looked to see whether the provider had implemented the action plan. We found the required improvements had been made to improve the rating of the service to good.

Follow up: The service will continue to be monitored through the information we receive.

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

Elmcroft Care Home provides accommodation, personal care and nursing care for up to 54 people. Some people have dementia related needs and require nursing care. The service consists of two units: the General Nursing Unit (GNU) and Blythe unit. At the time of our inspection there were 42 people living at the service.

A registered manager was in post at 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.

When we last visited the service in April 2017, we had found the care being provided was not consistently good. Whilst people in the GNU received good quality care, in the Blythe unit, care was not person-centred and people were not supported to engage in meaningful activities. We were also concerned that the manager had not put adequate processes in place to monitor people’s wellbeing.

At this inspection, we found the care people received had improved and was now consistent across the two units. A new activity coordinator had been appointed and people in the Blythe unit were receiving more personalised care.

In the period between the two inspections, a number of concerns had been raised following a specific complaint and a visit from an Environmental Health officer. These concerns had been acted on by the manager and improvements had been made, such as safer care for people using catheters and new kitchen equipment.

However, we were concerned however that the manager and provider had failed to put measures in place to pick up these issues in a pro-active manner. During our inspection we saw a number of tools to check the quality of the service had been recently been introduced and another set of measures were due to be implemented before the end of the year. Whilst these were positive, they had not been implemented in a timely manner after our last inspection and we were not able to measure how effective they were and whether any improvements were sustainable.

Staff, people and families were extremely positive about the registered manager. The manager promoted an open culture throughout the service and was now more visible in the Blythe unit. There was good communication at the service, and this was improving with the introduction of additional meetings with staff and families.

There was no longer a dedicated clinical lead at the service and the provider was recruiting for a new deputy manager. The manager was covering both posts and so their time was stretched. Nursing and care staff were focused on meeting people’s daily needs; however there was insufficient oversight and coordination of the care and domestic tasks being carried out. As a result the manager had not always picked up where there were gaps in staff skills.

People were supported to maintain good physical health. Staff ensured people had enough to eat and drink, and the dining experience had improved in the Blythe unit. At our last inspection we made recommendations around developing staff skills when supporting people with dementia and mental health issues. This was an area which required on-going improvement.

The manager was open and pro-active when safeguarding concerns were raised. There were effective plans in place to manage risk. There were sufficient, safely recruited staff to meet people’s needs, and there had been a focus on reducing the dependence on agency staff. Experienced staff were now working across both units so people were consistently cared for by staff who knew them. Medicines were administered safely by well qualified staff.

The service was meeting the requirements of The Mental Capacity Act 2005 (MCA). Assessments of capacity had been undertaken and applications for Deprivation of Liberty Safeguards (DoLS) had been made diligently to the relevant local authority. Assessments and care plans had been improved in the Blythe unit and better reflected people’s needs and preferences. Staff developed good relationships with people and families. People were treated with dignity and respect.

Whilst there had been some setbacks since our last inspection, there was a positive culture within the service. The manager and staff demonstrated a commitment to the needs of the people they supported and had worked hard to make improvements since our last inspection.

Elmcroft Care Home provides accommodation, personal care and nursing care for up to 54 people. Some people have dementia related needs and require nursing care. The service consists of two units: the General Nursing Unit (GNU) and Blythe Unit. At the time of our inspection there were 38 people living at the service, 25 in the GNU and 13 in Blythe Unit.

A registered manager was in post at 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.

When we last visited the service in 2015, we found the care in the GNU to be of a good quality and Blythe Unit was not occupied. At this inspection people living in the GNU continued to receive good quality care. However we had concerns regarding the experience of people living in Blythe unit which was now partially occupied.

People living in Blythe Unit had not been supported to settle into their new home in a positive way. The care they received was not person centred and stimulating. Staff did not know or treat people as individuals. Care plans had gaps and there was a focus on meeting physical needs, with insufficient information about people’s mental health needs, life histories and preferences.

The registered manager had failed to pick up and resolve the concerns in Blythe unit and to address the lack of consistency across the service.

Staff, people and families were extremely positive about the registered manager. The manager promoted an open culture and relaxed atmosphere in the GNU but the layout of the service meant they were not as visible on Blythe unit. Complaints and concerns were investigated thoroughly.

The manager communicated very well with people, families, staff and professionals. There were measures in place to monitor the quality of the service. Whilst these had not resulted in the manager dealing with the specific issues we found in Blythe unit, we found that in other instances audits and checks had been used to drive improvements.

People were supported to maintain good physical health. Staff ensured people had enough to eat and drink. We made recommendations around supporting people with dementia with their nutrition and hydration needs, in line with best practice.

Across the service, staff focused on keeping people safe. There were effective processes to manage risk. There were sufficient, safely recruited staff to meet people’s needs. Medicines were administered safely by well qualified staff.

The service was meeting the requirements of The Mental Capacity Act 2005 (MCA). Assessments of capacity had been undertaken and applications for Deprivation of Liberty Safeguards (DoLS) had been made diligently to the relevant local authority. Assessments and care plans within the GNU were complete and reflected people’s needs and preferences. Staff knew people well and were caring and person centred in their approach.

At this inspection on 24 June we found that improvements had not been sustained. We started our inspection of the service at 6am on 24 June 2014 so we could assess staffing levels on the night and day shift. We asked the provider to send us more information following the inspection.

We considered our inspection findings to answer 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?

This is a summary of what we found:

Is the service safe?

On the morning of our inspection we were met by staff, who checked our credentials and asked us to sign in the visitors book. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

On the day of our inspection we found there were sufficient staff at the service to provide care to the people who lived there.

People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained.

Is the service effective?

Care records we viewed contained information that had not been updated and revised to include the current appropriate, and relevant information in relation to people's care and support needs.

Is the service caring?

During our inspection we observed staff who spoke with people in a kind and caring manner. We saw that staff were responsive to people's care needs.

Is the service responsive?

People's care records showed that where appropriate, support and guidance was sought from health care professionals such as dietician and speech and language therapist. However guidance from these professionals was not always recorded in people's care plans.

The service did not respond to complaints in a timely manner.

Is the service well-led?

The service did not have a robust quality monitoring system in place. As a result the quality of the service had not been maintained.

On the day of our inspection, 38 people were living in Elmcroft care Home. We spoke with nine people during our visit and spent time observing the staff and people who used the service interact together. We also spoke with ten staff. A new manager had started work at Elmcroft Care Home and was undertaking their induction on the day of our inspection.

Many people were not able to talk to us verbally about their experience of the service so we used observation to understand their experiences. We looked at a range of records which included six people's care plans and daily records, staff training, staffing rotas, health and safety and quality checks.

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?

This is a summary of what we found;

Is the service safe?

Improvements had been made to people's safety and welfare. The care plans had been reviewed and updated with clear information about people's needs.

Where people were unable to make day to day or significant decisions, we saw that Mental Capacity Act (MCA) 2005 assessments had been undertaken and reviewed. Where it was necessary, Deprivation of Liberty Safeguard (DoLS) were in place. We saw that these had been completed appropriately in full consultation with relevant professionals in order to keep people safe from harm.

The provider had reviewed the dependency levels of people using the service since our last inspection. Staffing levels, as if for a full occupancy, had been retained in order to give people a quality service. Recruitment and training for staff was underway to improve their skills and to meet people's needs safely.

Staff knew about safeguarding people who used the service and what they should do if they suspected or witnessed abuse. This kept them and those around them protected from harm.

Is the service effective?

People's assessments showed that their care, support and treatment was planned and delivered in a way that ensured that their needs were being met.

People told us that they had access to health and social services. Health professionals were involved in providing specialist advice to ensure people who used the service received care that was planned and coordinated.

Is the service caring?

We observed the interaction between staff and people who used the service. People were relaxed and comfortable. Staff spoke with people in a kind and caring way, offering choices and encouragement. People who could tell us verbally said, 'They are all lovely (the staff), can't fault them.' Another person said, 'There is always a smile when they come into me, so friendly.'

Is the service responsive?

The monitoring and review of people's care needs had been improved. We saw staff interacted well with people and knew how to meet their individual needs. For people with one to one support, new ways of working had been implemented to enhance their independence and wellbeing. We saw staff responded appropriately to people's changing needs, wishes and interests.

The range of individual activities and entertainment had improved with the introduction of a programme based on people's interests and preferences. One person said, 'I like to be with everyone in the afternoon, it makes a change.' Another person said, 'There is a lot more to do now that we have that lady (the activities coordinator).'

Staff, residents and relative's meetings had been held after the last inspection to discuss the findings. People were able to express their views and the provider responded by drawing up a plan of changes. This meant that people felt listened to and valued.

Is the service well-led?

There had been some changes to the management at Elmcroft since our last inspection in February 2014. The area manager and clinical lead nurse were jointly managing the service to implement the necessary changes to care planning and delivery, training and quality assurance to ensure people were cared for appropriately and to a high standard.

The staff we spoke with were positive about the changes being made to the service for the people who used the service as well as themselves. One staff member said, 'The atmosphere is nicer, calmer and we have more time with people. It's so much better for them and us.'

The service had a quality assurance system in place and records seen by us showed that identified shortfalls were now being addressed. As a result the quality of the service was continuingly improving.

As part of our ongoing regulation of the service we received information from family members, staff members and the local authority which raised concerns in relation to staffing and people's care not being planned and delivered in a way that met their needs.

We found the service was not effective and people did not always experience care, treatment and support that met their individual needs, protected their rights and promoted their well-being. We found some people were socially isolated. There was a lack of meaningful interaction and engagement with people and as a consequence we saw people became agitated and distressed, others were lonely.

We spoke with three people and they each spoke highly of the staff team and said they worked hard and were mostly kind and caring. People told us that they felt there was not enough staff. We found that there were sufficient numbers of staff on duty however they were not deployed properly to enable people's needs to be met effectively at key times during the day. People using the service and staff told us that the home lacked management and leadership and communication was poor.

We looked at the systems in place to assess and monitor the quality and safety of the service and protect people against the risks of inappropriate or unsafe care. We found the systems in place were not managed effectively to properly identify failings in the quality and safety of the service provided; the home was not well led.

People had clear assessments of their needs and plans and strategies were in place to meet them. We saw that care workers interacted with people in a relaxed and respectful manner.

We found that people who were able to communicate with us felt they always had their consent to care and treatment sought, felt they were in control of their care and were having their choices and preferences respected. However it was unclear how consent to care and treatment was obtained from people with more complex needs. We found that people's care plans were sufficiently detailed however staff on both units told us they did not always have time to consult the care plans to see what treatment had changed. This placed people at risk of receiving care that was not appropriate or safe.

We found the staffing ratios were adequate most of the time on both units however the skills and experience of these staff did not always meet people's needs. People told us they felt there was not enough staff to see to their relatives needs and we observed that staff did not have time to spend with people.

Due to the complex needs of some people, we also spent some time observing people and saw that they were actively engaged in activities of their choice and at a level that was appropriate to them. Although no formal activities were taking place during our visit, we observed staff interacting positively with people and supporting them to listen to music, read the newspaper or watch television. One person told us, "It's my home and I do what I want to."

We noted that staff were respectful in their approach to people and treated them with dignity and respect, addressing them in a manner that was appropriate to them and which corresponded with their preferred method of address documented in their care records. People appeared content in the presence of staff and there was a friendly and calm atmosphere. Care records showed that relatives were encouraged to participate in people's care reviews and were kept updated with any changes in condition.