This inspection took place on 25 and 26 October 2018 and was unannounced.

We last inspected the service on 6 and 17 July 2017 and found the service to be in breach of Regulations 17 and 18 of the Health and Social Care Act 2008. Issues identified included staff not receiving regular supervision to support them in their role and the lack of regular monitoring and auditing to ensure that health care checks and monitoring were appropriately completed.

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 ratings of the key questions of effective and well-led to at least good.

Elmstead 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.

Elmstead House accommodates up to 50 people across two separate units, each of which have separate adapted facilities. One unit supports elderly people some of whom were living with dementia. The other unit is a functional mental health unit which supports people with recovering and enduring mental health problems. At the time of this inspection there was 37 people living at Elmstead House.

A manager was in post at the time of this inspection and had submitted an application to the CQC to become the 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.

At this inspection we found that the service had made improvements to address previous issues that we had found. However, further improvements were required in relation to staff receiving regular, formal supervisions and annual appraisals.

Staff that we spoke with confirmed that they felt supported in their role and received regular supervisions and annual appraisals. However, records seen did not always confirm this. The newly appointed manager was aware of this and had plans in place to ensure all staff received regular, formal supervisions and an annual appraisal.

People and their relatives told us that they felt safe living at Elmstead House. All staff demonstrated a good understanding of safeguarding people from abuse and the actions they would take to report their concerns.

People’s care plans contained comprehensive information about identified risks associated with their health and social care needs and clear guidance for staff on how to support people to be safe and free from harm.

Staffing levels were determined based on individual people’s levels of need. We saw that there were sufficient number of staff available around the home.

Recruitment processes ensured that only those staff assessed as safe to work with vulnerable adults were recruited.

People received their medicines safely, on time and as prescribed. Medicine policies and processes in place supported this.

Accidents and incidents were recorded, reviewed and analysed to ensure that where things had gone wrong improvements and further learning were considered and implemented.

Staff received a comprehensive induction when they first started work at the home with regular on-going training which enabled them to deliver effective care and support.

People’s needs and preferences were assessed prior to their admission to Elmstead House so that the home could confirm that these could be effectively met.

People had access to a variety of snacks, drinks and regular meals which helped them to maintain a healthy and balanced diet. Where people had specialist diets and support needs in relation to their dietary intake this was appropriately catered for.

People were supported to have maximum choice and contr

This inspection took place on 6 and 17 July 2017 and both days were unannounced.

Elmstead House is a nursing home that is registered to provide accommodation with nursing and personal care for up to 50 people. The service specialises in dementia, diagnostic and/or screening services, learning disabilities, mental health conditions, physical disabilities, and caring for adults over 65 years old. The home was divided into two units, one for people who are living with dementia and are physically frail, and the other for people with a mental health diagnosis. At the time of the inspection there were 36 people living in the home with 21 people in the dementia unit and 15 in the mental health unit.

We undertook a focussed inspection in November 2016 when we looked at three domains Safe, Effective and Well-Led. We found that the service required improvement in the Safe domain as staff practice was poor with regard to infection control that resulted in a breach of the regulations. We had concerns about the security of the building as such we made a recommendation the provider took advice from an expert in security management. During this inspection, we found that the concerns with regard to infection control and security of the building had been addressed.

At the November 2016 focused inspection we found the service required improvement in the Effective domain as there were significant gaps in health recordings as such the service did not maintain robust monitoring of people's wellbeing which was a breach of the regulations. In addition, although people were offered a choice of meals there was not always access to snacks and drinks during the day.

During this inspection, we found that there was a new and varied menu and we saw snacks and drinks being offered throughout the day. Most people’s health recordings such as food consumption charts, fluid charts, welfare checks, and repositioning charts were undertaken without omission. However, one person’s did not have accurate and complete recordings. Their repositioning charts contained gaps and their welfare chart contained gaps. Food charts were completed for all people but recordings did not contain information to show if the food given had been fortified as the dietician directed. Fluids charts showed clearly if people had received their identified intake for the day and the day recordings were without gaps. However, there was little or no recording of drinks offered or consumed at night. As such whilst we acknowledged improvements had been made there was still work to be undertaken to embed the recording system. As such, we found a repeated breach of the regulations.

In addition, during this inspection we found staff supervision sessions was not taking place for many staff. As such, we found a breach of regulations.

At our previous inspection we found Well-led inadequate as there was not a registered manager in post since January 2016 and staff morale was low. Although the service had undertaken checks and quality assurance audits these had not been effective in identifying and addressing the recording, infection control and security concerns we found during our inspection.

During this inspection, we found there was a manager in post who had applied to become a registered manager with the CQC. They became the registered manager shortly after our visit to 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.

We found that the staff morale had improved for some staff but not all. The provider had taken action to meet with staff. However, lack of staff supervision meant staff were not receiving either group or individual sessions to raise their concerns and have their performance fee

This inspection took place on 14 November 2016. It was an unannounced focussed inspection. We inspected for the domains of Safe, Effective and Well-Led.

Elmstead House is a nursing home that is registered to provide accommodation with nursing and personal care for up to 50 people. The service specialises in dementia, diagnostic and/or screening services, learning disabilities, mental health conditions, physical disabilities, and caring for adults over 65 years old. The home was divided into two units, one for people who are living with dementia and are physically frail, and the other for people with a mental health diagnosis. At the time of the inspection there were 44 people living in the home with 28 people in the dementia unit and 16 in the mental health unit.

Prior to this inspection we had carried out an unannounced comprehensive inspection of this service on 16 June 2015 at which two breaches of legal requirements were found. This was because people were not fully protected against the risks associated with medicines. There were also some gaps in records for people who were unable to consent to care and required best interest decisions to be made on their behalf, so it was not always clear if all relevant parties had been consulted in line with the Mental Capacity Act 2005. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We found the service was meeting these legal requirements when we undertook a focused inspection on the 10 December 2015.

The service had not had a registered manager since January 2016. 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. There was a recently appointed manager who told us they intended to apply for registration.

During our inspection we found three breaches of the regulations in infection control, nutrition and hydration and good governance.

Although staff had received infection control training we observed poor infection control practice in particular the disposal of protective equipment such as gloves and contaminated waste.

We found people were offered a good choice of meals however they did not have access to snacks throughout the day. In addition drinks were not available to people at all times. We found some fluid charts contained significant gaps in recording. This meant that people were not being effectively monitored to ensure they remained well hydrated.

Daily recordings such as re-positioning charts to manage pressure ulcers care contained significant gaps. This meant that people were not being monitored effectively to ensure their medical conditions were well managed. We found that the nursing staff were well informed about people’s health requirements. People were supported to access health care professionals. Nurses demonstrated they understood what medicines they administered were used for and we found medicines were stored safely. Administration was completed appropriately in the majority of instances.

Although there were governance systems in place to assure the quality of the service given we found that these had not been effective in monitoring and addressing the issues we found during our inspection. In addition staff morale was low and the provider had not ensured staff felt valued and listened to. Staff told us they were too short staffed at times to meet the needs of people living at the service. The provider demonstrated to us that they employed agency staff in response to staff absence and used a dependency tool to identify staffing need.

We found the service was not always safe as the service had been broken into twice in recent months and although some security measures had b

We carried out an unannounced comprehensive inspection of this service on 16 June 2015 at which two breaches of legal requirements were found. This was because people were not fully protected against the risks associated with medicines. There were also some gaps in records for people who were unable to consent to care and required best interest decisions to be made on their behalf, so it was not always clear if all relevant parties had been consulted in line with the Mental Capacity Act 2005.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We undertook a focused inspection on the 10 December 2015 to check that they had followed their plan and to confirm that they now met legal requirements.

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 ‘Elmstead House’ on our website at www.cqc.org.uk

Elmstead Nursing Home is a nursing home that is registered to provide accommodation with nursing and personal care for up to 50 people. The service specialises in: dementia, diagnostic and/or screening services, learning disabilities, mental health conditions, physical disabilities, and caring for adults over 65 years old. The home was split into two units, one for people who have memory problems and are physically frail, and the other for people with mental health difficulties. At the time of the inspection there were 44 people living in the home with 28 people on the dementia unit and 16 on the mental health unit.

The home 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 and associated Regulations about how the service is run.

At our focused inspection on 10 December 2015, we found that the provider had followed their plan which they had told us would be completed by 30 September 2015, and so legal requirements had been met.

Improvements had been made in the administration of medicines to people living in the home. The practice of delegating administration had stopped, and there were clear records of how people’s medicines should be administered particularly if they required covert medicines (without their knowledge) with consultation recorded with all the relevant people. There were regular audits of medicines administration, and all prescribed medicines were in stock and clear records of administration were recorded.

Improvements were made in recording people’s consent to care and best interest decisions made on their behalf under the Mental Capacity Act 2005. There were clear systems in place for assessing and monitoring people who were subject to Deprivation of Liberty Safeguards.

This inspection took place on 16 June 2015 and was unannounced. Elmstead Nursing Home is a nursing home that is registered to provide accommodation nursing and personal care for up to 50 people. The service specialises in: dementia, diagnostic and/or screening services, learning disabilities, mental health conditions, physical disabilities, and caring for adults over 65 years old.

The home was split into two units, one for people who had memory problems and were physically frail and the other for people with mental health difficulties. At the time of the inspection there were 46 people living in the home with 28 people on the dementia unit and 18 on the mental health unit.

The home 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.

Whilst most aspects of the home were safe, people were not fully protected against the risks associated with medicines. There were also some gaps in records for people who were unable to consent to care, and required best interest decisions to be made on their behalf, so it was not always clear if all relevant parties had been consulted. Some people expressed concerns over staffing numbers at weekends, during meal times and medicines rounds.

Staff showed a good knowledge of people’s life histories and preferences regarding their care and support needs. They knew what to do if people could not make decisions about their care needs, and the procedures for reporting abuse. Safe systems were in place for recruiting staff, and the home was kept clean and hygienic.

People were provided with a choice of food, and were supported to eat when this was needed, some improvements had been made to food provision following a recent food satisfaction survey. People had a range of activities available to them, organised by two activities workers.

People’s health needs were met, and they were supported to consult with health and social care professionals as needed without delay.

People had the opportunity to be involved in decisions about their care and how they spent their time at the home. They and their relatives attended meetings during which they could raise any issues of concern.

The provider had systems for monitoring the quality of the service and engaged with people and their relatives to address any concerns. When people made complaints they were addressed appropriately.

Staff received regular supervision and training relevant to their role. They felt well supported by the management, and able to speak up about issues of concern to them.

At this inspection there were two breaches of regulation in relation to medicines management, and compliance with the Mental Capacity Act 2005, and a recommendation is made regarding staffing deployment in the home. You can see what action we told the provider to take at the back of the full version of the report.

The relatives we spoke with were happy with the care their family were receiving, one relative said, “the staff phone me when my dad needs to see a doctor and then they call me back after, to tell me the outcome, this means I do not worry.”

We observed people on the mental health unit having breakfast, we saw that a choice was offered. At weekend’s people could have a cooked breakfast. People we spoke with all confirmed that the food was good.

Relatives and people we spoke to all confirmed there was enough staff. One relative said, “there always appears to be enough staff on when I visit my mum.”

We saw the service completed several audits; we reviewed the infection control audit and mattress and couch audit.

We reviewed the fluid balance charts, turning charts. We saw that on the whole charts were being completed. Staff we spoke with were aware how much people should be drinking and the importance of recording as soon as people have had a drink.

We carried out this inspection to check whether the provider had made improvements in the service since we last inspected on the 21 March 2013. At that inspection found that the provider had not assessed people's capacity related to consent to use covert medication.

At the inspection on the 5 June 2013 we found that where people did not have the capacity to consent, the provider acted in accordance with legal requirements. We saw that the manager had put systems in place to gain and review consent from people who lived in the home. We saw five documents that had to be completed before the person could commence on covert medication (medication hidden in food or drink). These documents involved all people who were involved in the person care, such as psychiatrist, doctor, relatives, home staff and pharmacist. This aimed to ensure that decisions taken were in the person's best interests. We could see how the covert medicine would be given and when the decision would be reviewed and by whom.

We spoke with five people, they told us "the staff are very friendly." one relative told us the care is very good. Many people were able to express their views but did not feel they had been involved in their care plans. One relative told us "I've never seen a care plan, but I would like too." When we visited peoples rooms we noted that staff had found out likes and dislikes and this was recorded on a chart in their rooms. We observed staff supporting people in daily activities. One person told us "you can talk to them about practically anything."

People told us that the home was kept clean and staff were aware of infection control polices and the importance of hand washing. One person told us "its kept spotlessly clean." Staff records were up to date and there was an effective recruitment and selection process for staff.

People who used the service and relatives were given the opportunity to discuss concerns in several ways through monthly group meetings or by the use of surveys. We saw that concerns and complaints had been acted on.

We saw that medication records were up to date and accurate and staff were appropriately trained in medication management. We found five people were on covet medication, some discussion had occurred with the multidisciplinary team but we saw no evidence in peoples care plans of any alternative methods that had been tried before the covert medication started. None of these people had received a capacity assessment.

People who use the service and their relatives expressed satisfaction with the care provided and they indicated that the care needs of people who use the service had been attended to. They stated that staff were friendly, pleasant and had treated them with respect and dignity. Their views can be summarised by the following comments :

"I am well cared for. I like it here.”

“Staff manage to do a good job.” (relative)

We observed that people who use the service appeared comfortable and well cared for. Assessments had been carried out and plans of care had been prepared for people who use the service. These had been prepared with the agreement of people who use the service or their representatives.

We noted that staff were interacting regularly with people who use the service and attending to the needs. Records indicated that effort had been made to provide a range of stimulating activities for people who use the service. The records indicated that staff had been given the necessary essential training.

The home had consulted and asked people who use the service and their representatives about their views and the results were available in the office. The feedback was on the whole positive.