An unannounced inspection was carried out at Elm Bank Care Home on 23 October 2018. An announced visit took place on 24 October 2018. This was a responsive inspection as we had received information of concern about the care home from external health and social care professionals.

Elm Bank 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.

Elm Bank is registered for 48 places but has 42 bedrooms (some of which were previously used as shared rooms). At the time of this inspection there were 38 people accommodated, including people who were living with dementia. The home was set over three floors, each of which had separate facilities.

There was a registered manager in post. They were not present at the time of the inspection. A ‘Resident Experience’ support manager was managing the service so we have referred to them as acting manager throughout this report. 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 provider’s governance systems had not always been rigorously or effectively applied. This meant several shortfalls in the standard of the service had not been identified by the quality audit processes. This is a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - good governance.

You can see what action we told the provider to take at the back of the full version of the report.

Prior to the inspection there were concerns that potential safeguarding incidents had not been acted upon and had not always been reported to the safeguarding authority. Also, unwitnessed falls and injuries had not been reported in line with local safeguarding protocols. This meant people had not always been protected from potential risk of harm. Recently, the acting manager had made sure that accidents and incidents were acted on, reported and appropriate preventative measure were put in place to reduce the risk of further harm.

Staffing levels were based on people’s assessed dependencies but the dependency assessment records were not up to date. Call bells were not always answered in a timely way so sometimes people had to wait for assistance. We have made a recommendation about this.

People said they felt safe and comfortable at the home. Risk assessments were in place about people’s safety and about the premises. The home was comfortable and maintained. There were some areas that needed attention to make them more easily cleanable. Medicines were managed in a safe way but there were some shortfalls in relation to medicine recording.

People who could express a view told us they received a “good service”. Before they moved to the home their needs were assessed to check if the home could provide the right care for them. Staff had opportunities for relevant training, although the induction of new staff and agency staff did not always show they were supported into their new role.

The assessments about some people’s capacity to make their own decisions was not always clear. Staff were going to have more training to help them understand the Mental Capacity Act 2005.

People now received the right support with their nutrition and hydration needs. Risks to people’s nutritional well-being were now assessed and managed. People said they enjoyed the meals and the quality of food was very good.

People and relatives told us staff were kind and caring. Staff were respectful and helpful when supporting people. There were friendly relationships between staff and the people who lived there.

There was a welcoming atmosph

We visited the home unannounced on 14, 19 and 20 December 2016.

We last inspected the service on 21 August 2015 where we found two breaches of Health and Social Care Act (Regulated Activities) Regulations 2014. These related to staffing and good governance. We also made four recommendations that best practice should be followed in relation to the management of medicines, the application of the Mental Capacity Act 2005 [MCA], the provision of a varied and balanced diet, and the décor and design of the service, particularly in relation to supporting people living with dementia. We asked the provider to take action to make improvements in these areas and this action has been completed.

Elm Bank Care Home provides accommodation and personal care for up to 43 older people, some of whom were living with dementia. Respite care and a day care service were also provided. The day care service is not regulated by Care Quality Commission (CQC) because it is out of scope of the regulations. There were 41 people using the service at the time of the inspection.

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.

At the last inspection, we found that there were insufficient staff to meet the needs of people, particularly those living with dementia. We found that staffing levels had been increased and we observed that care was unhurried and people told us they were attended to promptly.

At the last inspection we found that governance arrangements in place had not identified all the shortfalls we found during our inspection. During this inspection we found that improvements had been made in all areas we had identified. There were improvements to the safety of the premises and equipment, and the home had been refurbished and redecorated, taking into account 'dementia friendly' design best practice. Feedback had been taken on board and acted upon.

Following our recommendation at the last inspection, we found that medicines were managed safely. Records were accurate and complete, and there were safe systems in place for the ordering, receipt, storage and administration of medicines. Quantities of medicines we checked were correct, meaning stock levels were accurate.

Risks to people and the environment had been assessed, and were regularly reviewed. We found that the staff and registered manager were not sufficiently aware of the status of a pressure ulcer of one person, who was being attended to by a district nurse. We made a recommendation that best practice should be followed in relation to the monitoring of skin integrity.

Staff had received training in the safeguarding of vulnerable adults and were aware of what to do in the event of concerns. Suitable recruitment practices were in place which supported safer recruitment decisions and helped to protect people from abuse.

The premises were clean and well maintained. Infection control procedures were followed by staff. Some unsuitable flip top bins we saw on the first day of the inspection, were replaced. There were no widespread malodours, and any issues with odours were addressed at the time they occurred.

Staff received regular training, supervision and appraisals. Recently introduced training in supporting people living with dementia had proven popular with staff who described to us the impact it had had on their approach, and the increase in empathy they felt towards people.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. MCA is a law that protects and supports people who do not have ability to make their own

We visited the home unannounced on the 21 August 2015.

The home was last inspected in August 2013. We found that they were meeting all the regulations we inspected.

Elm Bank Care Home provides accommodation and personal care for up to 43 older people, some of whom were living with dementia. Respite care and a day care service were also provided. The day care service is not regulated by CQC because it is out of scope of the regulations.

There were 39 people living at the home on the day of our inspection. Accommodation was spread over three floors. There were 16 people living on the top floor and a further 11 on the ground floor who had general personal care and support needs. 12 people who had dementia related conditions lived on the middle floor.

A manager had been in post for almost four years. She was registered with CQC in line with legal requirements. A registered manager is a person who has registered with the Care Quality Commission (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 and associated Regulations about how the service is run.

The manager stated that they staffed over and above the levels recommended by the provider's staffing tool. We found however, that staffing levels did not always allow staff to deliver a flexible and responsive service. Safe recruitment procedures were followed and staff said that they undertook an induction programme which included shadowing an experienced member of staff.

There were safeguarding policies and procedures in place. Staff were knowledgeable about the actions they would take if abuse was suspected. One relative contacted us prior to our inspection regarding their concerns about certain aspects of care and support at the home. We passed these concerns onto the local authority’s safeguarding adults team. The local authority’s safeguarding team were also investigating concerns regarding medicines. We cannot report on these at the time of this inspection. CQC will monitor the outcome of the safeguarding investigations and actions the provider takes to keep people safe.

Checks and tests were carried out to ensure that the premises and equipment were safe. However, some of the décor and furnishings were worn and in need of updating. There was an odour of stale urine around the middle floor. In addition, the environment was not supportive of the needs of the people who lived there. We have made a recommendation that the design and decoration of the premises is based on current best practice in relation to the specialist needs of people living with dementia.

We checked medicines management and had concerns with the recording of medicines. Medicines administration records (MARs) contained duplicate entries of medicines and it was not clear whether certain medicines had been administered because staff had not signed against each entry. We have made a recommendation that best practice is followed in relation to medicines recording.

Staff told us that training was provided. They explained that most of the training was e-learning. Some staff told us that more face to face training, especially in dementia care, would be beneficial. We observed that staff did not always know how to effectively communicate and interact with people who lived on the dementia care unit. Following our inspection, the regional manager informed us that further training had been organised.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005. These safeguards aim to make sure that people are looked after in a way that does not inappropriately restrict their freedom. The manager had submitted a number of applications to the local authority to deprive people of their liberty in line with legal requirements. We noticed however, that mental capacity assessments and best interests decisions had not always been carried out for all “decision specific” issues. We have made a recommendation that people’s records evidence that care and treatment is always given in line with the Mental Capacity Act 2005.

The manager stated that menus were discussed and agreed with people according to their likes and dislikes. We found however, that the menu was repetitive and did not always evidence that people had access to a range of healthy meals and snacks. We have made a recommendation that the provider follows best practice guidelines to ensure that people receive a healthy and nutritious diet.

We observed that care was provided with patience and kindness and people’s privacy and dignity were respected. Most people and relatives spoke positively about the service. One relative said, “Very good care home - we went round three or four locally and that was the best.”

An activities coordinator was employed to help meet the social needs of people who lived there. The manager stated that the activities coordinator took people out into the local community. The activities coordinator organised arts and crafts and games on the day of our inspection. We saw however, that activities provision for people who lived on the dementia unit was not always appropriate or effective.

A new electronic monitoring system had been introduced. An iPad was located in the foyer of the home. People, relatives, staff, health and social care professionals were able to provide feedback via the iPad. This feedback was immediately sent to both the home and regional managers. This enabled the manager and the provider to obtain immediate feedback and insight into the service.

A new deputy manager had been in post for three months. However, no supernumerary hours were allocated to enable him to update care plans, carry out audits and checks and monitor the provision of care on the dementia care unit.

A staffing tool was used to assess staffing levels at the home. The manager told us however, that this tool did not take into account the needs of people who had a dementia related condition.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014. These related to staffing levels and governance. The action we have asked the provider to take can be found at the back of the report.

We spoke with 10 people who lived there and also a relative to find out their opinions of the home. Some people were unable to communicate with us due to their condition. Those who could, informed us that they were happy with the care provided.

We found before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. One person said, “They always ask before doing anything, we work as a team.”

People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. One person told us, “We have a very honest decent time here, they care very effectively.”

We received mixed opinions from people and staff about whether there were enough staff to look after people. One person said, “Sometimes there are not enough staff but we are never left in the lurch.” We found that there were enough qualified, skilled and experienced staff to meet people’s needs.

There was a system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service. We found that records were kept securely and could be located promptly when needed.

At this inspection we saw that a new care plan system had recently been introduced. We noted that the new documentation was based on a more person centred approach. We found that people’s personal records were now accurate and fit for purpose.

People spoken with said they were happy at the service. People said they had choices in how they spent their day and staff respected their wishes about routine. One person said “I was watching the entertainment but I’ve had enough so I got x (care staff) to bring me out”.

People confirmed that they received enough food and drinks and were well looked after. One person said “before I came here I was always ill, I think I wasn’t eating enough. Now I’m a lot better”. Another said “I saw my Doctor the other day, he couldn’t believe how well I looked for my age”.

One person told us “I feel safe here, the staff are lovely, it’s warm and clean, what more can you want”.