This inspection took place on 5, 7 and 8 June 2018 and was unannounced.

Elderholme 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 service accommodates up to 64 people in single rooms all located on the ground floor. During the inspection, there were 63 people living in the home.

At the last inspection in March 2017, the registered provider was found to be in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as medicines were not always managed safely, risk was not always assessed accurately and we identified some concerns regarding the safety of the environment. We asked the provider to complete an action plan to show what they would do and by when to improve the key question of whether the service was safe, to at least good.

During this inspection, we looked to see if they had made the necessary improvements and found that although some changes had been made, further improvements were required to ensure the provider was fully compliant with Regulations.

A registered manager was 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. We asked people living in the home and their relatives their views on how the home was managed and feedback was positive.

We could not check the stock balance of some medicines as records did not all accurately reflect how many medicines should be in the home. Not all medicines had been administered as they had been prescribed. Although the registered manager had developed a template for PRN (as and when required) protocols, we found that these protocols were not always in place, or were not accurate. Some medicines were stored securely in people’s bedrooms; however the temperature of the rooms was not monitored. The provider was still in breach of Regulation regarding this.

At the last inspection we found that risk assessments contained inconsistent information. During this inspection we found that risks to people had been assessed consistently. We looked at accident and incident reporting within the home and found that they were recorded electronically and appropriate actions were usually taken following any incidents.

CQC had not been notified of all events and incidents that occurred in the home in accordance with our statutory requirements, particularly incidents relating to safeguarding issues raised by other organisations.

Audits were completed to ensure the registered manager could monitor the quality and safety of the service. Although audits were completed regularly, we found that they did not highlight all the issues identified during the inspection.

People told us they felt Elderholme was a safe place to live. Staff were aware of adult safeguarding and knowledgeable about procedures to follow if they had any concerns and how to whistle blow if they did not feel that concerns were addressed appropriately. Most safe recruitment processes had been followed when staff were employed, but records did not always clearly show when staff were shadowing other staff members as part of an induction.

There were enough staff on duty to meet their needs in a timely way. During the inspection we observed that call bells were answered quickly and staff were available to provide support when needed.

People at the home were supported by the staff and external health care professionals to maintain their health and wellbeing. Staff completed training and were assessed regularly to ensure they were competent in their practice.

Menus were displayed aroun

This inspection took place on 1 and 2 March 2017 and was unannounced.

Elderholme Nursing Home is situated within the grounds of Clatterbridge Hospital on the Wirral. It is a single storey purpose built care home offering both nursing and personal care for up to 61 people. All 61 bedrooms are single occupancy. There are three communal lounges, two main dining rooms and a pleasant garden with seating area for people to access. It also provides short term care for people who require assessment prior to returning home or moving to long term care.

During the inspection, there were 57 people living in the home.

We last completed a comprehensive inspection of Elderholme in February 2015. We found that the provider was in breach of regulations with regard to person centred care, consent and good governance. The service was rated as ‘requires improvement.’ In June 2015, we conducted a focused inspection to check that improvements had been made. We found that the provider was meeting regulations in relation to consent and good governance. The overall rating for the service was not reviewed during that inspection.

During this inspection we found that care files we viewed were detailed and person centred. They contained information specific to the individual, such as their preferred hobbies, their family history, previous occupations and preferred daily routines. This helped staff get to know people as individuals and provide care based on their experiences and preferences.

Staff we spoke with knew the people they were caring for well. We asked staff about people’s preferred foods and specialist dietary requirements and all staff had a good understanding and the information they told us was reflected in people’s care plans. The provider was no longer in breach of this regulation.

Most risk assessments we viewed had been completed accurately, however we found that some contained inconsistent information. This meant risk to the person may not have been accurately identified; however we found that appropriate care had been provided. We discussed this with the registered manager and on the second day of inspection, they told us that the risk assessments had been updated. We looked around the home and found that risk was not always minimised. For instance, we saw a fire door wedged open and chemicals were not always stored securely.

Medicines were stored safely and the temperature of the room was monitored daily as well as the medicine fridge and they were within safe ranges. Medicine Administration Record (MAR) charts were not always completed fully as gaps were evident in the recording of medicine administration. We checked the stock balance of one medicine with gaps evident on the MAR chart and found that there were more medicines left than there should have been. Staff had completed training in relation to safe medicine administration and had their competency assessed each year.

We found that staff were kind and caring in their approach when supporting people and we observed staff respecting people’s dignity in a number of ways during the inspection. We found however, that people’s privacy and dignity was not always maintained as information specific to individuals and their needs, was visible around the home. This meant that private information about people was accessible to people who did not require to see it and this did not protect people’s dignity.

People told us they felt safe living in Elderholme and relatives we spoke with agreed that the home provided a safe environment for their family members to live in. All staff we spoke with were aware of safeguarding procedures and how to raise concerns.

Records showed that staff were recruited safely and most people told us there were enough staff on duty to meet people’s needs in a timely way and our observations confirmed this. Call bells were answered quickly and people did not have to wait for support when they requested it.

Records showed that incidents were recorded and

We carried out an unannounced comprehensive inspection of this service on 11 and 13 February 2015. At this inspection a breach of legal requirements was found. This was because the provider had failed to protect people from the risks of inappropriate or unsafe care; had failed to ensure people’s consent was legally obtained in relation to the care they received and had failed to ensure that adequate quality monitoring systems were in place to ensure the service was well led.

We issued the provider with a warning notice in relation to their breach of people’s legal right to consent to their care and treatment. A warning notice is an enforcement action used by the Care Quality Commission to direct a provider to improve their service to meet requirements of a specific regulation within a set time period. We gave the provider until the 11 May 2015 to meet their legal requirements in relation to consent.

We requested an action plan from the provider in respect of the other breaches found during our inspection. After the comprehensive inspection, the provider submitted an action plan outlining the improvements they intended to make to meet the legal requirements in relation to safe care and treatment and quality monitoring.

We undertook a focused inspection on the 17 June 2015 to check that they had met the requirements of the warning notice and their action plan in order to meet, the legal requirements in relation to the breaches described above. This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘ Elderholme Nursing Home’ on our website at www.cqc.org.uk’

Elderholme Nursing Home provides accommodation with both personal and nursing care for up to 61 people. The home is single storey and set within the grounds of Clatterbridge Hospital. All 61 bedrooms are single occupancy. There are three communal lounges/dining rooms and a pleasant garden with seating area for people to access.

The home also offers an intermediary care service. This means that the home offers support to people discharged from hospital who require a period of rehabilitation before they are ready to return home independently. There are 14 beds reserved for this purpose.

The home had a registered manager in place who, was in attendance during our inspection. 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.

An inspector and a specialist advisor in end of life care carried out this inspection. As part our inspection 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. Below is a summary of what we found.

Is the service safe?

We looked at the care records of three people who lived at the home. We found that each care record contained information about people’s physical health needs and risks and how these were to be managed. Care records however lacked sufficient detail in some areas for example emotional well being and people's preferences and did not adequately assess all of the risks. This meant people were at risk of receiving inappropriate or unsafe care that did not meet their needs. We found that one person's care had not always been delivered in accordance with their individual plan of care. This meant they had not always received the care and support that was planned for.

We have asked the provider to tell us what improvements they will make in relation to the planning and delivery of safe and appropriate care.

Is the service effective?

We observed that staff gained people’s consent before providing assistance with their day to day needs. Records showed people had consented to various aspect of care for example the taking of weight measurements and the use of photographs. We found however that one person who was identified as lacking capacity, had not had a mental capacity assessment undertaken in relation to the decisions they were able to make. There was also evidence that this person's refused consent was not fully respected.

We have asked the provider to tell us what they are going to do to meet the legal requirements of the Mental Health Act 1983 and the Mental Capacity Act 2005.

Is the service caring?

Two of the people we spoke with said staff were kind and treated them with dignity and respect. They said “The matron is nice, the staff are all nice” and “Staff are lovely, can have a laugh, everybody is top notch”. One person we spoke with said that staff “were okay I suppose” but that some staff were impatient. We observed staff supporting people throughout the day. We saw they were kind, attentive and supported people at their own pace. We saw that people were given appropriate information and support to express their views and make decisions in relation to their care and life at the home.

Is the service responsive?

Care records outlined what people could do independently and what they needed help with. This enabled people's independence to be promoted by staff in the delivery of care. Information about people’s preferences, interests and aspirations and how the service was responding to these needs was however limited. A range of activities were provided by the home such as muscial bingo, exercise class, book club and visits to the cafe. This ensured people's social and activity needs were responded to. Records also showed that referrals to health and social care services such as GPs, dietetic services, speech and language therapy and mental health support were made promptly in relation to people’s health needs.

Is the service well led?

We found that their were systems in place at the home to monitor the quality and health and safety of the service provided for example accident/incident, medication, equipment, infection control and environmental audits. The provider’s health and safety practices and fire risks were recently externally audited and the provider had clear plans in place to address any hazards or risks identified. A complaints policy and satisfaction surveys were undertaken to record people’s views on the quality of service provided. We found that any complaints received were dealt with appropriately and that people, relatives and visiting professional had expressed overall satisfaction with the service provided.

We spoke with four people who lived at the home. People told us they were treated with dignity and respect and were well looked after. They said “it’s very good",“staff are brilliant” and “ they take care of us”. We observed people were well cared for and treated kindly.

We saw that people's needs were assessed and regularly reviewed. Care records were personalised, promoted a person's independence where possible and included information about a person's likes and dislikes.

Where people had limited mental capacity, care plans explained how to communicate with people so they were able to make decisions about their day to day care. Staff we spoke with were knowledgeable about a person’s needs and understood the person’s right to refuse consent.

We reviewed three staff records. We found the provider had undertaken the necessary checks to ensure people had the necessary skills and suitability to work with vulnerable people. Staff had received regular training in safeguarding and demonstrated a general awareness of abuse. People we spoke with said they had no concerns or worries and felt safe with staff.

A well publicised complaints policy was in place which was clear and simple to follow. People we spoke with said they had no complaints but would know how to make a complaint. We reviewed the handling of one complaint and saw the provider had investigated and responded to the complaint in a sensitive, prompt manner to the person's satisfaction.

Elderholme is a registered charity with a board of directors. A chief executive acts as a general manager to represent the board but he has no involvement with nursing or personal care which is the responsibility of the registered manager.

We spoke with four people living at the home who told us they were very happy with the home. One person said “It’s my home.” They told us the staff were always respectful and very helpful. They told us the food was good and that they were given choices in what they wanted to eat. One person told us “the staff know I don’t like certain foods on the menu and always give me a choice of something different.”

We saw that staff were well supported to carry out their role and received regular training. We found that there was quality assurance monitoring systems in place.

We spoke with a person who lives at the home and was sitting outside the front door in the sunshine with a volunteer visitor. The volunteer said that he visits the home once a week and has a chat with some of the men especially about football. The resident said that he was very happy and enjoys trips out on the minibus. When we were leaving, a group of residents was sitting outside at the front of the home and they said they were enjoying the sunshine. A visitor was sitting with them and they were having birthday cake.

The expert by experience who visited the home with us found that:

On entering the home residents are asked to sign to say their bedroom door will be open but they can ask for it to be closed.

One resident of three months informed me that there were regular residents’ meetings. Many residents said if they had any complaints they would talk to the matron. Their comments included ”staff are very helpful, I would speak to matron if anything was wrong”, “they jump to it when asked to do anything”, “no complaints would tell matron if I had”, “staff are very good, especially one”. Another person said ”no complaints someone comes round every hour and half to keep tabs (at night)”.

Buzzers were to hand in the rooms, which were clean and personalised; residents are encouraged to have their own furniture etc. The rooms, which were light and airy, looked out onto the well cared for gardens with bird feeders hanging from many of the windows. If the residents go out into the garden there is a system in place of hand held call alarms.

A younger lady who had been in the home for six years and was confined to her bed was quite happy and comfortable with her treatment. She said “the staff are very good to me”. If there were any complaints she would let the matron know. One gentleman remarked that after supper ”they tend to get you in your room early”. Many residents stay in their own room. It was a calm and peaceful home no one voiced any complaints. Everyone said the staff were good and food was good.

There is a weekly survey of a number of residents. Ten different questionnaires are available to assess the wellbeing of residents and any complaints they have.

A visitor observed that she was pleased with the progress the staff had made with the long standing problem of ulcers on her friend’s legs. The hospital hadn’t been able to cure them, but with trying various treatments since arriving in the home the staff had cured them.

In one dining room residents were brought to their tables at 12.05 for 12.30, which seemed a bit early. A larger display of menus, stating the alternative choices, is needed to avoid residents having to ask. Menus are needed on the tables or on a large whiteboard in the dining rooms. I was told residents would have been told what lunch was but no one seemed to know. The lunch menu is posted on all the information boards but only one choice is displayed. Residents can have something else but no other choice is shown. There are no menus on the tables or on the dining room walls.

Lunch was minced beef pie with sauté potatoes and green beans. No other choice was displayed. Residents are asked when they get to the table, do they want this, no other choice is suggested at this time only when the resident refuses are they offered another choice.

I was shown to one of the dining rooms, most of the residents were seated and some were eating their meals. The tables were well presented with white damask tablecloths and napkins, a glass, knife and fork, and dessert spoon, a small posy of flowers and white matching condiment set in the middle of the table. The staff who all wore plastic aprons were asking some of the residents did they want these aprons some agreed some refused. Two ladies on my table were wearing the heavy duty aprons. These two ladies found it very difficult to eat the mince, the gravy was quite runny, they both struggled to eat with the knife and fork and even though our table was in a prominent position no one came to them to ask if they could manage, nor suggest they use the spoon.

Later on clearing the plates away when the food had gone cold, the staff asked one of the ladies who had left quite a lot – did she not want it? She was not offered anything else. The portions were small and no one was asked could they eat anymore. The sweet was egg custard, I did hear people being asked when they refused would they like ice-cream. There was no pastry around this egg custard and again the ladies found this difficult to eat- it was wobbling all over the spoon- a fork to push it onto the spoon would have been very useful, but none was provided.

Glasses were filled with orange juice and regularly topped up if wanted, but no other juice was on show. I enjoyed the food it was quite tasty. I was positioned with my back to a table were one member of staff was spoon feeding three people. I turned around occasionally to watch. Another staff had been feeding a lady very quietly in one corner but, as the lady kept dropping off to sleep, she would then come and sit at the end of the table behind me, and proceed to feed another lady who had her head slumped onto her chest. Although this was done very quietly, because of all the interruptions it was not appropriate, and although other staff were taking food out to other places there were still enough to help to feed these people. After the meal everyone was asked would they like coffee or tea.

All the residents praised the food “food excellent” “food good”. One of the residents said ” if I don’t like food I’ll go and see the cook and it’ll be changed”. I asked one resident about choice and whether he knew what was for lunch ”didn’t come round last night not forewarned” “can have a cooked breakfast, egg on one toast, don’t get bacon and egg together, can have cereal and bacon sandwich”. I asked about lunch “don’t get told choices, don’t like curry usually ham sandwich” but he likes chips he can have them anytime.

The expert by experience considered that bigger portions could be offered and more help for residents that find it difficult to eat- or at least special cutlery and dishes, would possibly help them to keep their independence for much longer.

At our last inspection in May 2014, breaches of legal requirements were identified. We asked the provider to take appropriate action to ensure improvements were made. We undertook this comprehensive inspection on the 11 and 13 February 2015. During this visit we followed up the breaches identified during the May inspection and found the provider had not taken appropriate action in relation to people’s care and welfare and how people’s consent was sought prior to care being given.

Elderholme Nursing Home is single storey building set in the grounds of Clatterbridge Hospital. There are 61 single occupancy bedrooms. The home provides support for people with both nursing and personal care needs. The home also provides an intermediary care service. This means the home offers support to people discharged from hospital but who need a period of rehabilitation before they are ready to return home independently. There are 14 beds reserved for this purpose.

The registered manager of the home at the time of our inspection was on planned sick leave and did not participate in the inspection. 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 breaches of Regulations 9,10, and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to Regulation 9,17 and 10 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 this report.

The majority of people felt safe living at the home and said staff treated them well. One person and one relative however reported that some staff had at times spoken to people in an inappropriate manner. We did not observe any inappropriate behaviour during our visit.

We found people’s care plans did not cover all of people’s needs and risks. Where risk assessments had been undertaken, risk assessment actions were not always acted upon to ensure people received the support they required and remained safe.

The provider’s emergency procedures required improvement to ensure people were safely evacuated. People without accessible call bells in place had not had the individual risks associated with this, assessed properly and, where call bells where in place, sometimes the staff response to people’s calls was not always prompt.

Where people had challenging behaviours, appropriate risk assessments had not been undertaken to ensure people were supported appropriately. Dementia care and person centred planning was poor and people’s care plans lacked information on people’s emotional and social needs. Where people had episodes of challenging behaviour or upset, care plans lacked information about how to alleviate their distress.

Some people who lived at the home had short term memory loss or dementia type conditions. People’s capacity had not been assessed, they had not been supported to participate in decision making and best interest decisions had not been undertaken appropriately. Where people required the protection of a Deprivation of Liberty Safeguard (DoLS), there was no evidence of why it was required or any evidence that any least restrictive options had been explored.

The majority of people thought staff had the right skills and knowledge to care for them but relative’s views were mixed. We looked at how the provider appraised, supervised and trained staff at the home. We found some gaps in the training of some staff members and found staff were supervised in groups.

The provider had a range of audits in place to check the quality of the service. Some of the systems however were ineffective. Care plans audits did not identify the gaps or inconsistencies in people’s information or ensure risks were properly assessed and managed. Some of the actions identified in the weekly medication audit had not been acted upon and accident and incident audits were too brief to enable the provider to learn from and prevent similar accident/incidents occurring. The continuing breaches identified at the last inspection were also not picked up and addressed by the provider’s quality management system.

People views were sought through the use of satisfaction surveys and resident meetings but none of the people we spoke with felt they had a say in the running of the service. Surveys were not analysed to enable the provider to come to an informed view of the quality of the service.

Staff were recruited in line with the provider’s own recruitment policy and appropriate checks on their safety and suitability to work with vulnerable people had been completed prior to employment. The number of staff on duty was sufficient to meet people’s needs. Staff we spoke with had an understanding of the care people required. They were also knowledgeable about types of potential abuse and what to do if they suspected abuse had occurred.

The home was clean, safe and well maintained. We saw that the provider had an infection control policy in place to minimise the spread of infection and a good supply of personal and protective equipment. For example, hand gels, disposable aprons and gloves. The home had recently been visited by Wirral NHS Infection Control Team and scored well in all areas.

The majority of people we spoke with at the home said they were well looked after and the staff were lovely. Most of the relatives we spoke with, confirmed this. We observed staff to be kind and respectful and the home provided a range of activities to occupy and interest people. This promoted their well-being.

People had access to sufficient quantities of nutritious food and drink and they were given a choice of menu options. Staff offered people support with their meals, assisted and encouraged people to eat when required. We observed a medication round and saw that it was administered to people in a safe way.

The people we spoke with had no complaints and were positive about the staff. One person and two relatives we spoke with had made complaints and were happy with the way they had been dealt with. Complaints records showed complaints had been responded to appropriately.