About the service: Leonard Elms is a nursing home. People in nursing 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 comprises of The Cherries and The Elms units. The Cherries unit specialises in dementia care and the Elms unit is for general nursing care. The home can accommodate up to 37 people and on the days of our inspection, there were 27 people living at

the service.

People’s experience of using this service: Bed rails were not within recommended guidelines set to ensure they were safe.

• Shortfall relating to bedrails that posed a risk of people climbing over them and a missing care plan had not been identified prior to our inspection.

• Audits were in place for infection control, environment, care plans, medicines management, food and fluids records, complaints and water temperature checks.

• People were supported by staff who were kind and caring. Staff knew people well and supported people in a respectful manner.

• Care plans were personalised. However, we found one person on a short term stay did not have a care plan in place to provide staff with guidance and any risks the person presented.

• Relatives, people, and staff felt the service was safe. Staff were able to recognise abuse and who to go to.

• Staffing levels were adjusted to reflect people’s needs. Medicines were safely stored however the policies and information staff had access to could be improved.

• Recruitment procedures were completed before new staff began work. Relatives spoke positively about the food provided at the service. The service was clean and tidy.

• People were supported by staff who received training. However, supervision was not always being provided in line with the member of staff’s agreement.

• One member of staff required an appraisal and there was no overview system that confirmed who had received one or when their’s was due.

• People had access to activities.

• Staff encouraged people to remain independent and provided privacy and dignity.

• Relatives felt able to talk to the management of the service and raise any concerns or issues should they need to.

Rating at last inspection: Requires Improvement (March 2018)

Why we inspected: This was a planned inspection based on the previous rating.

Enforcement: We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and we made one recommendation relating to undertaking care plans for people on short term stays. Please see the ‘action we have told the provider to take’ section towards the end of the report

Follow up: We will review the report on actions the provider intends to take following the inspection. We will continue to monitor the service through the information we receive. We will inspect in line with our inspection programme or sooner if required.

This inspection took place on the 29 and 31 January 2018 and was unannounced.

At our last inspection in July 2017, we found breaches of legal requirements. This was because we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 .These related to unsafe care and treatment; poor governance and the need for consent.

This service has been in Special Measures since June 2016 and at least one domain has been rated Inadequate since October 2015. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures. However, it is rated as Requires Improvement as further time is needed to demonstrate the improvements can be sustained.

Following the inspection in November 2016, we imposed a condition on the provider's registration. This was to prevent new people from being admitted into the home. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and when. We found that during this inspection the action plan had been followed and improvements had been made.

Leonard Elms 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 comprises two units, the Cherries and the Elms. The Cherries unit specialises in dementia care and the Elms unit is for general nursing care. The home can accommodate up to 73 people and on the days of our inspection, there were 31 people living at the service.

There was 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.

At our previous inspection, people were not always receiving safe care and treatment as medicines were not consistently managed safely. At this inspection, we found sufficient improvements had been made. Medicines were stored and administered safely to people living at the service.

At our previous inspections, people who lacked capacity did not always have decisions made following the principles of the Mental Capacity Act 2005. Improvements had been made. Staff understood the importance of seeking people's consent to care and treatment in line with legislation and guidance. Information about the service was made available to people in user-friendly formats and staff communicated with people in the way best suited to their needs.

We have made a recommendation to the provider regarding the involvement of people’s legal representatives, when people cannot make decisions for themselves.

At our previous inspection, we found that people were not always receiving individualised care. At this inspection, improvements had been made. People received care that was responsive to their needs. Staff worked in a flexible way in response to people's needs. Some people preferred to spend time in their rooms rather than the communal lounge and this was respected. Staff learnt about people's needs from reading their care plans and talking with them and their relatives. However, not all care plans reflected this.

At our previous inspection, we found that people's records were not always completed

We undertook an inspection on 13 and 19 July 2017. Before the inspection, we had received a number of concerns about the level of care provided by the service. This was a comprehensive inspection and followed up concerns from our last inspection in February 2017. At the February 2017 inspection we found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. The breaches related to safe care and treatment; good governance; safeguarding service users from abuse and improper treatment; fit and proper persons employed; need for consent; staffing and failing to submit statutory notifications of incidents that affected the health, safety and welfare of people. The service has been in special measures since February 2016. In November 2016 the Commission imposed a condition on the provider’s registration that the service must not admit any new service users for the purposes of the regulated activity.

Leonard Elms Care Home provides accommodation for people who require nursing and personal care, including those living with dementia. The service comprises of two units, the Cherries and the Elms. The Cherries unit specialises in dementia care and the Elms unit is for general nursing care. Prior to this inspection CQC had restricted admissions at the home. The home can accommodate up to 73 people and on the days of our inspection there were 36 people living at the service.

There was not 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 current manager has submitted their registered manager’s application to CQC for consideration.

At our previous inspection, people were not always receiving safe care and treatment. At this inspection, we found insufficient improvements had been made. Medicines were not consistently managed safely. People were not consistently cared for in a safe and clean environment. The delivery of care did not ensure that people’s risks were adequately managed.

At our previous inspections, people who lacked capacity did not always have decisions made following the principles of the Mental Capacity Act 2005. Although improvements had been made consent to care was not consistently sought in line with legislation and guidance.

At our previous inspection, we found that people were not always receiving individualised care. At this inspection, insufficient improvements had been made. Care plans were not consistently detailed to help staff provide personalised care based on current needs. They were not consistently written in conjunction with people or their representatives.

People's records were not always completed correctly or monitored to manage their health conditions.

People and their relatives felt that the staff were caring. Staff were knowledgeable about people's needs and told us they aimed to provide personalised care to people. The observed dining experience was mixed. It did not consistently enhance social interaction between people or fully enable choices.

At our previous inspection, we found the provider failed to notify CQC of all incidents that affected the health, safety and welfare of people who use the service. At this inspection, sufficient improvements had been made. The provider is now submitting statutory notifications, when required.

At our previous inspection, people were not always being protected by the recruitment process. At this inspection records showed that a range of checks had been carried out on staff to determine their suitability for work.

At the previous inspection, there were inadequate systems and processes in place to protect people from abuse.

Leonard Elms Care Home provides accommodation for people who require nursing, personal care and dementia for up to 73 people. The home comprises of two units; the Cherries and the Elms. The Cherries unit specialises in dementia care and the Elms unit is for general nursing care. Prior to this inspection CQC had restricted admissions at the home. On the days of inspection there were 42 people living at the home. The accommodation is arranged in two buildings adjoined by a reception area; one building is for each unit. Most people living with dementia were unable to express their views regarding the support they received. During this inspection the reception area was undergoing some refurbishment.

At the time of this inspection the home was still in special measures. Services in special measures will be kept under review. Adult social care services can remain in special measures for 12 months.

At the last inspection, in June 2016, we found breaches in the home because staff were not receiving all the training they required. Care plans were not always complete for people and still did not reflect their needs. People were unsafe because there were issues with pressure care, risk of choking and medicine administration. We found the home was not well led because there were no auditing systems in place and they had not identified all the shortfalls we found. Following the last inspection the provider sent us an action plan and further regular information about the work they had been doing to meet the regulations. At this inspection we found there had been some minor improvements. Concerns were still found in most of the areas where shortfalls had previously been raised.

Prior to this inspection some further concerns had been received by us. As a result the inspection date was brought forward to follow up these issues. This inspection was unannounced and took place on the 8, 10 and 13 February 2017.

At this inspection the registered manager was present on the first two days of the inspection. A registered manager is a person who has been 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, some nurses and team leaders. The provider was at the home for all three days.

People told us they felt safe and we found some improvements for people who were at risk of choking. However, there continued to be risks to people’s safety around pressure care, risk assessments, medicine administration and responses to accidents. Specialist mattresses for pressure care were still not always set correctly. When people were at risk of pressure related wounds care there was sometimes a lack of guidance for staff to follow. There was not guidance for staff to follow for people prescribed creams. Often these were to moisturise skin to prevent pressure wounds.

Before the inspection we had been alerted by the local authority and the provider of an incident where a person using the service was scalded by a hot drink. This incident is subject to a criminal investigation and as a result this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of scalding and the treatment of injuries. This inspection examined those risks.

Most staff received regular supervisions and appraisals. The provider and management supported staff. There had been small improvements with the training staff received. However, staff still did not get all the training they required to carry out their duties to keep people safe and meet their needs.

Staff were aware of their responsibility to protect people from avoidable harm or abuse and most staff had received training in s

Leonard Elms Care Home provides accommodation for people who require nursing, personal care and dementia for up to 73 people. The home comprises of two units; the Cherries and the Elms. The Cherries unit specialises in dementia care and the Elms unit is for general nursing care. The Cherries unit holds a level three accreditation in the Butterfly Project by Dementia Care Matters. This is a specialist approach designed around entering the world of the person with dementia. On the days of inspection there were 45 people living at the home. The accommodation is arranged in two buildings adjoined by a reception area; one building is for each unit. Most people with dementia were unable to express their views regarding the support they received.

At the last inspection, we found breaches in the home because staff were not receiving regular supervisions or appraisals and there was a shortfall in training. Concerns were found with food preparation areas and chemicals were not being stored securely. Care plans were not complete for people and did not reflect their needs. People were unsafe because there were issues with pressure care and medicine administration. We found the home was not well led because there were no auditing systems in place and they had not identified all the shortfalls we found. Since the last inspection, the provider and registered manager have been sharing changes they had made in the home. Although there had been some improvements, we found there were still concerns.

This inspection was unannounced and took place on the 27, 28 and 29 June 2016.

The registered manager was the acting manager at the last inspection. A registered manager is a person who has been 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, some nurses and team leaders.

People told us they felt safe but there continued to be risks to their safety around pressure care, risk assessments, medicine administration and incident reports. The provider had sourced specialist mattresses for pressure care but these were not always set correctly. People were not being reviewed regularly to ensure their pressure care was relevant. Some people were put at risk if they required special medicine patches. Planned procedures in case of fire were not identifying the risks people could be placed in.

People had a choice of meals, snacks and drinks, which they told us they enjoyed. The chef provided alternative options if people did not want what was on the menu to ensure their preferences were met. However, there were times people’s weight was not being monitored and the provider had not identified the risks of choking for people if they required a special textured diet or thickened drink.

Staff were now receiving regular supervisions and appraisals. There had been some improvements with the training staff received. However, staff did not get all the training they required to carry out their duties to keep people safe and meet their needs.

Staff were aware of their responsibility to protect people from avoidable harm or abuse and most staff had received training in safeguarding. Staff knew what action to take if they were concerned about the safety or welfare of an individual. However, there were no systems in place to ensure all incidents which should be reported were. The recruitment process did not always follow good practice, which meant people were exposed to risk from staff who had not had the correct checks conducted by the provider.

The registered manager and staff had an improved understanding about people who lacked capacity to make decisions for themselves. There had been some improvement in recording decisions made in a person’s best interest. However, the cor

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

Leonard Elms Care Home provides care and accommodation to up to 73 older people. The home comprises two units known as The Cherries, which provides care to people with dementia, and The Elms which provides nursing care. There were 51 people living at Leonard Elms Care Home at the time of our visit. This was an unannounced inspection, which meant the staff and provider did not know we would be visiting.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law, as does the provider.

Improvements were needed so that people were provided with a good level of safety in all areas. This meant ensuring risks within the environment were identified and reduced as far as possible. The procedures for recruiting staff were also not as thorough as they should have been.

Systems were in place for monitoring the service, however these did not always ensure that shortcomings were being found and responded to promptly. Although we had received a number of notifications during the last year, these did not cover all relevant events.

People received an effective service. This was because staff received training which helped them to do their jobs well. Staff understood the importance of supporting people with their nutrition and ensuring that any concerns about their health were followed up promptly.

A system was in place for assessing people’s needs and for the planning of their care. However there were shortcomings in how the system was being implemented and records did not always provide good information about people’s care.

Staff were caring and the people who lived at the home were treated with respect. The relationships between staff and the people at the home were friendly and positive.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

People that we spoke with during our inspection gave positive feedback about the care provided at Leonard Elms. One person visiting the home said that "I visit quite often and find it a lovely happy place". Another person said that "coming here is the best thing that happened to me". We made observations during our visit of staff being attentive and caring towards the needs of people in the home.

People were protected against the risks of poor nutrition because their weight was monitored. Where there were concerns about an individual's weight, this was discussed with relevant the professionals. Food was offered in sufficient quantities and people who required it were offered support to eat and drink.

Staff told us they felt supported by management in the home. Training was provided to ensure that staff had adequate skills to support people in the home; this included specific training in dementia and the Mental Capacity Act 2005.

There were systems in place to monitor the quality of the service provided and this included gathering the views of people in the home, their relatives and other healthcare professionals. There was a complaints procedure in place and this was on display in the home so that people were aware of how to raise issues or concerns.

Leonard Elms care home is made up of two units, called The Cherries and The Elms. The Cherries provides care for people with dementia and The Elms provides nursing care. During our visit, we inspected both units and our findings are reported about the home as a whole.

During our visit we saw that people appeared happy and settled. Some of the people that we met were able to tell us that they were happy living at Leonard Elms. People and their relatives had opportunity to be involved in making choices about their care, for example by attending care plan reviews. A relative that we met during our inspection confirmed that they were kept informed of any important information about their family member.

We saw that people had access to an activity programme, and observed people enjoying and engaging in an activity on the afternoon that we visited.

We saw that staff were aware of correct manual handling techniques and received training to help them do their jobs. We were told that staff are provided with half an hour study time on a regular basis, and this time could be used to familiarise themselves with people's care plans. We found that care plans were detailed enough to support staff in caring for people at the home, and risk assessments were in place to ensure that people were protected.

At our previous visit in September 2011 we had concerns that peoples changing needs had not been identified and actions were not put in place to address these changes. This related to weight loss and risk of falls. We also found that care needs and delivery was not documented accurately.

Staff that we spoke with told us they were aware that some people had undergone reviews by other health professionals. They gave positive feedback regarding the referrals with all staff being made aware of the outcomes. In one example they were aware that a review had resulted in changes to care and the provision of hip protector garments for one person at risk of falls.

We spoke with staff about the training they had attended for nutrition. They told us they had used the knowledge they had gained telling us, “we have good improvements in peoples food intake. One lady who did not eat much now has finger food and eats very well”. We spoke with the chef about meal choices for people who prefer a vegetarian diet as previously we had found that choice was limited. The chef had revised the daily menu sheet so that it included a choice of seven vegetarian meals.

Comments from staff were positive with them telling us “team working has now improved“ and “we are able to give people individual care rather than being task orientated”. An example of this was at breakfast time staff told us they help people eat their breakfast and then assist them with personal care. The manager told us that care staff were now more engaged in thinking about care delivery in a person centred way rather than focusing on tasks.

People who use the service that we spoke with told us “I can choose to have a bath if I wish and what time I want to get up”. People felt that their families were involved in their care “my son is always chatting to the staff”. Others felt supported to keep in contact with old friends with one person telling us “I go to visit my friend every week”.

Staff we spoke with told us that relatives have input into peoples needs and that they can be involved in care reviews. We spoke with staff that had been working at the home for up to four years and others that had been employed for four weeks. All staff told us that they had induction training when commencing employment at the home. All had completed training in manual handling, which included a practical session which was useful in knowing how to use the hoist and other aids. We had concerns that some manual handling practice we observed did not demonstrate staff had awareness of the correct and appropriate equipment to use.

Some people using the service who required a vegetarian diet were not able to make a choice for their meal at lunchtimes. We spoke with staff who told us that they were not aware of any choices for a vegetarian option and that the meal would be whatever the kitchen sent up.

We had concerns that recording of information to monitor people’s fluid intake and weight were not fully completed to enable monitoring of needs. Peoples care needs were not always assessed and reflected in their care plans, so as to ensure their care and welfare was met. We also saw that staff were carrying out care which was not in line with some people’s care needs assessments.

Since our previous visit in June 2011 the provider had increased the number of staff. There was an additional care assistant on duty every day on the upper floor of the Leonard dementia unit to provide support, especially at mealtimes. The Elms nursing unit staffing had increased by one care assistant between 2pm and 8pm each day. Staff on each unit told us that the additional numbers had made a difference to the workload

Due to our review being centred on the dementia unit at Leonard Elms Care Home, we received few comments from people about their experience of the service. Some people that use the service were seen to be having cooked breakfast and told us ‘’this is very nice, I like this’’

Our review raised concerns that people who use the service are not having their needs met due to a permanent manager not being in post to lead the service.

People cannot be confident that events which affect their welfare have been reported to the appropriate bodies, so that where needed action can be taken. Although information about the quality and safety of the service is collected, people do not benefit from this being used to make improvements and changes to reduce risks to their health and well being. People who use the service are not protected from the risks of inadequate nutrition and hydration by provision of food and drink in sufficient quantities to meet their needs. Support for people with eating and drinking is limited.

Since the date of our site visit to Leonard Elms Care Home, the provider Mr Paul Bliss has supplied us with information which sets out the actions being taken to address the concerns raised in this report.

Leonard Elms Care Home provides accommodation for up to 73 people who require personal care and nursing. The home comprises of two units, the Elms and the Cherries; the Elms unit is for general nursing care. The Cherries unit specialises in dementia care and has recently gained a level three accreditation in the Butterfly Project by Dementia Care Matters. This is a specialist approach designed to be person centred and enter the world of the person with dementia. On the day of inspection there were 55 people living at the home. The accommodation is arranged in two buildings – one for each unit.

This inspection was unannounced and took place on 28 and 29 October 2015.

There is a registered manager in post for 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. However, we were told that the registered manager has not been actively at the home for three months; the provider has an acting manager in post, who is a registered manager for another home owned by the provider. The acting manager is supported by the registered manager and operations manager.

People told us they felt safe but there were risks to their safety including pressure care and medication management. Key staff had not received training in pressure care and the management systems did not always identify pressure wounds. Medication procedures were not following best practice and this was putting people at risk. The upkeep of the building was potentially putting people at risk and there were concerns about measures in place to prevent fires. Issues were found about the storage of food in fridges and freezers.

There were concerns about the supervision and training staff received. The staff were aware of their responsibility to protect people from avoidable harm or abuse and some staff had received training in safeguarding. Staff knew what action to take if they were concerned about the safety or welfare of an individual. They told us they would be confident reporting any concerns to a senior person in the home and they knew who to contact externally. The recruitment process followed good practice.

The provider and senior management had some understanding about people who lacked capacity to make decisions for themselves. However, many of the staff had not received appropriate training. Care plans had not made it clear the consultation process when people lacked capacity or that people had decision specific assessments. When there were decisions to prevent people leaving the home for their safety the correct processes had not always been followed. As a result, there were breaches of people's human rights.

The registered manager and provider had not followed their legal obligations to notify CQC of their absence and they had failed to notify CQC of other incidents. The acting manager told us that they had not completed any up to date quality assurance procedures; the systems were not identifying all shortfalls in the home.

There were concerns around care plans for people because they were not always complete; in some cases people had no care plan. These plans did not have a person centred approach to them; this means that people were not central to their care and decisions being made. The use of a computer based system meant that generic phrases were created for people rather than specific ones to reflect their needs and wishes. Care plans were not always responsive to changes in people. Staff had some knowledge about the care plans, but explained they found it difficult to access them because there were limited computers.

Staff supported people to see a range of health and social care professionals to help with their care. Staff supported and respected the choices made by people especially in the Cherries Unit.

People had a choice of meals, snacks and drinks, which they told us they enjoyed. The chef provided alternative options if people did not want what was on the menu to ensure their preferences were met.

People and their relatives thought the staff were kind and caring; we observed mainly positive interactions. The privacy and dignity of people was respected most of the time and people were encouraged to make choices throughout their day.

People knew how to complain and there were good systems in place to manage the complaints. The registered manager and acting manager demonstrated a good understanding of how to respond to complaints.

The acting manager had some visions for the home and had some systems in place to communicate this.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and breaches in the Care Quality Commission (Registration) Regulations 2009. We are currently considering the action we will be taking.