About the service: Elburton Heights is a care home that can accommodate up to 85 people that require nursing or residential care. At the time of the inspection 61 people were living at the home. The service is split into four units that offer either nursing services or residential care. Two units look after people living with dementia; one is a nursing unit and one is a residential unit. There is a further nursing unit and another residential unit.

Rating at last inspection: The rating at the last inspection was Requires improvement overall. The report was published on the 24 September 2018. This service had been rated repeat Requires improvement at the previous two inspections and we had met with the provider to discuss our findings and their subsequent actions.

Why we inspected: We inspected because we received concerns about people’s care from a variety of sources. CQC have been liaising closely with the local safeguarding adults team. The areas of concern were used to inform our planning for this inspection.

Enforcement: Following our last inspection we found four breaches of regulations. There was a lack of appropriate records, which placed people at risk of receiving inappropriate care. Not all staff were receiving appropriate training, supervision and appraisal, necessary to carry out their

duties. The provider has failed to ensure people received safe care and treatment and risks to people's health and safety had not been fully assessed and measures to reduce risks were not fully effective. The provider had failed to have effective governance systems and quality assurance processes to assess, monitor and drive improvement. At our last inspection we told the provider to provide us with an action plan about how they would ensure compliance with the regulations and by when.

This was a repeated 'Requires Improvement' rating so we met with the provider in December 2018 for reassurance that there would be improvements. We placed two conditions on the location registration that:

1. The Registered Provider will complete monthly audits of staff training and supervision, service users’ records relating to their current care and risks, medicine management, audits relating to the environment: and write a report on what you have found, with the actions you intend to take as a result of these audits.

2. The registered provider will send the commission a monthly report on the 1st working day of each calendar month the findings and actions of the points above.

Despite this, at this inspection this rating had deteriorated to ‘Inadequate’.

At this inspection we found action had not been taken to address all the concerns and breaches of regulations found at the previous inspection and we found these areas had deteriorated and were inadequate as well as finding further concerns.

People’s experience of using this service

• The quality of people's care raised serious concerns, mainly related to the nursing units known as Willow and Maple where 39 people were living.

• People that were dependent on staff to pre-empt and meet their needs were being failed by the service.

• People were not receiving care that was fully safe, effective, caring, responsive to their needs and well-led.

• The service is now judged to be inadequate in keeping people safe, providing effective care, as well as a lack of caring and responsive support, and leadership.

• Most people living on the nursing units, Willow and Maple, were living with dementia or conditions affecting their communication and/or understanding. Therefore, they were unable to comment on their direct experience of living at Elburton Heights. Relatives and staff all told us how they had concerns and had brought them to the manager and staff on the nursing units but had not seen an improvement.

• There was a severe lack of staffing numbers to enable people’s needs to be met on Willow and Maple which resulted in poor care and people’s basic needs not being met.

• Risks in relation

The inspection took place on the 30 and 31 July and 6 August 2018 and was unannounced.

Elburton Heights is a care home that can accommodate up to 85 people that require nursing or residential care. At the time of the inspection 69 people were living at the home. The service is split into four units that offer either nursing services or residential care. Two units look after people living with dementia; one is a nursing unit and one is a residential unit. There is a further nursing unit and another residential unit.

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 service did not have 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. The service was currently being overseen by a registered manager of another Harbour Healthcare service with the support of the regional manager because the service was in the process of recruiting a new manager for Elburton Heights.

When we completed our previous comprehensive inspection on 27 and 28 April 2017 we found the areas of effective and responsive and well led required improvement with a breach of Regulation in responsive.

At that inspection we found concerns that people were not being assessed in line with the Mental Capacity Act 2005 as required. We also found that though some people had care plans in place to reflect their current needs, people living with dementia were not having their needs planned for. We recommended that the provider looked at this to ensure they were following current guidance. Some people’s records of their daily life were not robust enough to demonstrate the care given. We had recommended the provider reviewed this. People were at risk because the provider's systems to monitor the quality of the service were not fully effective and had failed to identify or address areas where improvements were needed. At that time the leadership, governance and culture did not ensure staff had sufficient information to ensure people's needs were fully met and staff were not well supported to enable them to consistently and safely deliver good quality care.

This inspection in July 2018 was a comprehensive inspection that looked at all areas of the service again to check the service had addressed the concerns from April 2017. We found the service had made improvements in some areas while other areas now required improvements. At this inspection we rated the service as Requires Improvement.

People's capacity to make important decisions about their lives had now been assessed in accordance with the Mental Capacity Act 2005 (MCA). The provider and staff understood their role with regards to ensuring people’s human and legal rights were respected. For example, the Mental Capacity Act (2005) (MCA) and the associated Deprivation of Liberty Safeguards (DoLS) were understood by the provider. They knew how to make sure people, who did not have the mental capacity to make decisions for themselves, had their legal rights protected and worked with others in their best interest. People’s safety and liberty were promoted.

People’s care and support was based on legislation and best practice guidelines, helping to ensure the best outcomes for people. People’s legal rights were upheld and consent to care was sought.

People’s care records were detailed and personalised to meet individual needs. Staff understood people’s needs and met them. People were not all able to be fully involved with their support plans, therefore family members or advocates supported staff to complete and review people’s

The inspection took place on the 27 and 28 April 2017 and was unannounced. This is the first inspection since the service was registered with this provider in June 2016.

Elburton Heights is registered to accommodate up to 85 older people. The service is split into four units that offer either nursing services or residential care. Two units look after people living with dementia; one is a nursing unit and one is a residential unit. There is a further nursing and residential unit. When we inspected 64 people were living at the service.

A registered manager was employed to manage 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. They were supported by a deputy manager, administrator and unit leads.

Where people were not able to consent to their care, staff did not always ensure people were assessed in line with the Mental Capacity Act 2005. Also, people living with dementia did not have a dedicated care plan in place for staff to understand how each person’s dementia journey was affecting them. We have recommended the provider refers to current guidance on best practice in respect of care planning for someone living with dementia.

When we looked at the records of how people passed their day, what activities they had completed and how staff had met their care needs, we found these to be incomplete, lacking personal detail and had gaps. Also, we found that different units were holding information of people’s care in different ways. We have recommended that the provider ensures they are recording people’s day to day lives in line with current guidance.

The registered manager and provider completed regular audits to check aspects of the service were running well. These had identified some but not all of the issues we identified. Action was not then recorded as to how this omission was being addressed.

People, relatives and staff were involved in giving feedback on the service. Everyone felt they were listened to and any contribution they made was taken seriously.

People told us they were safe and happy living at Elburton Heights and were looked after by staff who were kind and treated them with respect, compassion and understanding.

People felt in control of their care. People’s medicines were administered safely and they had their nutritional and health needs met.

People could see other health professionals as required. People had risk assessments in place so they could live safely at the service. These were clearly linked to people’s care plans and staff training to ensure care met people’s individual needs. The identifying and assessing of people’s individual risk was inconsistent.

People’s care plans were written with them, were person centred and reflected how people wanted their care delivered.

People were provided with enough to eat and drink to maintain their welfare. We have recommended the provider reviews how they monitor people’s nutritional and hydration needs.

Staff knew how to keep people safe from harm and abuse. Staff were recruited safely and underwent training to ensure they were able to carry out their role effectively. Staff were trained to meet people’s specific needs. Staff promoted people’s rights to be involved in planning and consenting to their day to day care.

Activities were provided to keep people physically and cognitively stimulated. People’s faith and cultural needs were met.

We found a breach of regulation. You can see at the end of the full report what action we have requested the provider take