We conducted an inspection of Ellesmere House on 21, 22, 26 and 29 June 2018. The first day of the inspection was unannounced. We told the provider we would be returning for the remaining days.

At the last inspection on 6, 7 and 10 July 2017, we asked the provider to take action to make improvements in relation to medicines management and this action has been completed.

Ellesmere House 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. Ellesmere House provides care and support for up to 70 people who require nursing and personal care. There were 62 people using the service when we visited. The home is divided into four units. Two 15 bed units located on upper floors provide accommodation for people with nursing needs. A 20 bed unit on the first floor is allocated to frail older adults requiring nursing care and the lower ground floor provides residential care for people living with dementia.

There was no registered manager at the service, however the manager had applied to register with the Commission and their application was being processed. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider ensured there were enough suitably trained staff to care for people.

Care staff received an induction and ongoing support through supervisions and appraisals to ensure they were competent in their roles.

Risks to people’s care were investigated and risk management guidelines were put in place. Care staff were aware of the risks to people’s care and had a good understanding of how to mitigate these.

There was a safeguarding policy and procedure in place which was understood and implemented by care staff. Care staff were aware of the need to report concerns.

The provider followed good infection control practices and the home was clean and odour free throughout our inspection.

People were given appropriate nutritional support. People’s care records included detailed information about their needs and kitchen staff were aware of these.

People’s care records contained a good level of information about their healthcare needs and care staff had a good understanding of how to support people with these.

People using the service and their relatives were involved in decisions about their care and how their needs were met.

The organisation had good systems in place to monitor the quality of the service. Audits were conducted by the manager on a monthly basis and further monitoring was conducted by the regional manager.

The provider followed safe medicines practices although guidance in relation to ‘when required’ medicines was not always clear. We recommend that the provider seeks further advice in relation to this area of their practise.

Staff a good understanding of their responsibilities under the Mental Capacity Act 2005. People were provided with care in line with their valid consent and this included implementing best interest decisions where needed, in accordance with legislation.

People gave good feedback about their care workers and told us they were caring. Care workers had a good understanding of the people they were supporting and we observed people being treated in a kind and dignified way. People confirmed their privacy and dignity was respected and care staff gave us examples of how they ensured this.

People knew how to make complaints and there was an appropriate complaints policy and procedure in place.

The provider conducted a varied activities programme and monitored people’s involvement in these.

This inspection took place on 6, 7 and 10 July 2017. The first day of the inspection was unannounced. We informed the manager we would be returning to complete the inspection on subsequent days.

At our previous inspection on 25 and 28 September 2015 we found the provider was meeting the regulations we inspected. We indicated that some areas of service delivery required improvement.

Ellesmere House provides accommodation for up to 70 people and is currently divided into four units. Two 15 bed units located on upper floors provide accommodation for people with nursing needs. A 20 bed unit on the first floor is allocated to frail older adults requiring nursing care and the lower ground floor provides residential care for people living with dementia. There were 70 people living in the home at the time of our inspection.

The manager was relatively new in post. She had begun the application process with the CQC to become the registered manager of the home. 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.

People told us they felt safe and comfortable with the staff providing care and support. Staff members wore uniforms and name badges making it clear what their role was within the home.

Although the provider had taken steps to ensure that risks to people's health and safety were being assessed and monitored, we found incidences where recording charts were not always being completed.

Assessments were completed to identify people’s support needs and this information was used to develop their care plans. Care planning records demonstrated that people’s capacity was assessed and documented in their care files.

The provider had systems in place to ensure people were protected from the risk of harm. Staff received safeguarding training and were familiar with the provider’s policies and procedures in relation to safeguarding vulnerable adults and reporting any concerns. Staff understood the principles of the Mental Capacity Act 2005 (MCA) and promoted people’s rights to make choices and decisions.

People were supported to maintain good health and had access to healthcare services and visiting practitioners when required.

People's medicines were stored safely. However, staff were not always observing that people had taken their medicines before signing medicines administration records (MAR).

Robust recruitment practices were in place to ensure people received care and support from staff who were suitably qualified and had the experience to carry out their duties effectively.

People’s privacy and dignity was promoted and staff recognised the importance of encouraging people to maintain as much independence as they could.

Where people required support to eat and drink, staff provided people with appropriate support and encouragement.

The service advertised a programme of activities and we were shown pictures of past events and social occasions. However, activities were not always taking place according to the schedule.

People and their relatives told us they had been provided with information about how to make a complaint. Not everyone felt their complaints were listened to.

There were protocols in place to monitor the quality of the service. A range of audits, maintenance and fire checks were carried out on a regular basis. However, these systems were not always identifying and managing the shortfalls we found during the inspection process.

The provider had systems in place for gathering feedback, including visits by Healthwatch dignity champions, relative's surveys and care plan reviews. Daily handovers, supervision and meetings were used to reflect on the standard of care practice and discuss how the service could implement improve

Ellesmere House is a care home providing support to up to 60 elderly people, some of whom have dementia. The home has a rehabilitation unit, two nursing units and a residential dementia unit.

We carried out a follow up inspection on the 27th August 2014 to check whether appropriate action had been taken to provide people who used the service with one to one activity plans and adequate stimulation to meet their needs. There were 57 people living at the home on the day of our visit.

People we spoke with told us they liked living at the home and that staff were caring. One person who used the service told us the activities coordinator was "very, very good" and that the home was "a very happy place." Another person told us they "enjoy all of the activities" and have "great fun."

The home had activity schedules posted on the walls along with pictures of residents engaged in past activities and projects. There were two good sized seating areas where activities took place. The home had a sensory room although we did not see this in use on the day of our visit.

We saw a group of people taking part in a morning exercise and music session. In the afternoon we saw that some people were doing a jigsaw puzzle together and others were engaged in a mixed activity session with one of the activities hostesses.

Although the provider had taken steps to provide training to staff and organise appropriate activity projects for people with dementia, we did not see activities taking place in the sensory room, on a one to one basis or with people who were confined to their rooms.

We saw staff interacting with people who used the service but there was some evidence that staff did not always deliver care or provide support that met people's individual needs and/or was safe and appropriate.

People living at Ellesmere House were known by staff and we observed some positive interactions between individuals and staff. We observed people receiving appropriate and safe care. People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. We observed staff throughout the day treating all people with respect. Personal care was carried out in private ensuring the dignity of all of the people being assisted and supported. There were male and female carers working at the home. People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

The provider does need to ensure that appropriate activities and one to one stimulation is provided to all of the people living at Ellesmere House.

The provider had an effective system to regularly assess and monitor the quality of service that people receive. People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. People were made aware of the complaints procedure and this was provided in a format that met their needs.

People living at Ellesmere House interacted with staff and it was evident that staff were known to them. Comments made by people living there included "the staff are very good here".

People living at Ellesmere House told us that the home was comfortable and that staff were respectful and caring. They were happy to be in the home and one comment made was "I feel safe here". Another person told us "I have lived here for two years and my family live close so its perfect".

The people we spent time talking to were aware of the complaints procedure and would talk to the management team if they had any issues.

People living at Ellesmere House told us that the home was very nice and that staff were respectful and caring. They were happy to be living at the home and enjoyed their independence. One comment made was "I have lived here for two years and could go anywhere; however I choose to live here".

The people we spent time talking to were aware of the complaints procedure and would talk to the manager if they had any issues.

Residents told us that the home was very nice and that staff were respectful and caring. They were happy to be in the home and enjoyed their independence. Some of the residents did report they sometimes got bored during the day. Generally the residents enjoyed the food in the home. Their relatives could visit at any time.

We carried out an unannounced comprehensive inspection of this service on 5 and 6 March 2015. We identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment. We also identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to good governance and as a result, issued a warning notice.

Following the inspection in March 2015, we asked the provider to send us an action plan by 15 July 2015 describing the actions they were going to take to meet the legal requirements and what they intended to achieve by their actions. We received the provider’s action plan on 11 June 2015.

Due to the significant number of breaches we found during our previous visit, we undertook another full comprehensive inspection on 25 and 28 September 2015. We wanted to check that the provider had followed their plan of action and confirm the service now met legal requirements. The first day of the inspection was unannounced.

Ellesmere House provides accommodation for people requiring nursing and personal care. The service can accommodate up to 50 people. The home is currently divided into three units. Two 15 bed units located on upper floors provide accommodation for people with nursing needs. A 20 bed unit on the lower ground floor is allocated to people living with dementia. The provider has submitted an application to add a new 20 bed unit which is currently being considered by our registration team. At the time of our inspection 41 people were using the service.

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.

People’s needs were assessed and care plans were developed to identify what care and support people required. Individual risk assessments had been completed for people living in the home and these were reviewed monthly in line with the provider’s policies and procedures.

During our visit, we observed one incident of unsafe practice in relation to the moving and positioning technique of care staff and observed one incident where people’s dignity was not being maintained or respected.

The home was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act (MCA) 2005, Deprivation of Liberty Safeguards (DoLS) and to report upon our findings. DoLS are in place to protect people where they do not have capacity to make decisions and where it is regarded as necessary to restrict their freedom in some way, to protect themselves or others.

Staff had received training in mental health legislation and senior staff understood when a DoLS application should be made and how to submit one. DoLS applications had been made in relation to a number of areas including access in and out of the building and continuous support and supervision.

Staff had previous experience of working in care settings. Most of the staff had completed training in dementia awareness and many had completed or were working towards completing training linked to the Qualification and Credit Framework (QCF) in health and social care. Staffing levels on the day of our visit were adequate to meet the needs of people living in the home.

We saw evidence that the home worked collaboratively with health and social care professionals to ensure people received specialist care and treatment. Specialist nurses, occupational therapists, dentists and podiatrists visited the home on a regular basis. The service maintained a diary detailing all healthcare appointments people were required to attend and had systems in place that ensured people were seen by the appropriate healthcare professionals at the appropriate time.

Staff demonstrated that they understood how to recognise the signs of abuse. Staff told us they would report any concerns to senior members of staff who would then assess the situation and report to the local authority’s safeguarding team and the Care Quality Commission (CQC) as required.

The home organised a range of activities and employed two full-time and one part-time activities co-ordinators. Activities included church services, birthday parties, sing along sessions and games. Newspapers were delivered to people’s rooms on a daily basis. People’s participation in activities in and outside of the home was recorded in a daily record.

A pictorial menu board displayed meal choices although these were not always displaying the actual meals available on the day. Staff were not always ensuring that people who were served meals in the dining areas and in their rooms were in a suitable upright position (where appropriate), to reach their food and eat it without unnecessary difficulty. People’s opinions as to the quantity, quality and choice of food on offer, were mostly positive.

We made two recommendations relating to staff training and people’s dietary and nutritional needs.