This inspection was unannounced and took place on 20 September 2017. At the last inspection in July 2016, we found the provider was not meeting fundamental standards and we identified a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked them to make improvements to staffing levels, staff recruitment systems, medicines management, maintaining people’s dignity, supporting people to make choices and take part in activities and quality assurance. Following the last inspection the service was rated as requires improvement.

The Elms Care Home is registered to provide accommodation with personal care for up to 13 older people including people with physical disabilities and people living with dementia. On the day of the inspection there were seven people living at the home. There was a registered manager in post. 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 2008 and associated Regulations about how the service is run.

Improvements had been made to the provider’s recruitment processes to ensure staff were safely recruited and were suitable to work with vulnerable people. People received their medicines as prescribed and systems used to manage medicines had been improved to ensure they were safe and effective. There were sufficient numbers staff to meet people’s care and support needs and respond to people when required. Risk management processes had been reviewed to ensure staff received appropriate guidance on how to manage risks associated with people’s safety, health and well-being.

Improvements had been made to the way in which people’s capacity to make decisions had been assessed and recorded. Clear information was now available to staff on how to support people to make their own decisions where possible, or to support decisions being made in the person’s best interests. Since the last inspection changes had also been made to the daily menus and people were now being offered a choice of meals. Snacks were also readily available to people to encourage a healthy nutritional intake. People were supported by staff who had the skills and knowledge to meet their care and support needs. People were supported to access healthcare professionals when they needed to and staff were aware of people’s health needs and how best to support them.

We found improvements had been made to the way people were supported which ensured their dignity and privacy was maintained. People told us staff were kind and caring and we observed caring interactions between people and staff throughout the inspection visit. People were supported to maintain their independence where possible and were involved in decisions about their day to day care and support. Visitors were welcomed and known by staff, who recognised the importance of people maintaining relationships that were important to them.

Improvements had been made to the range of activities available for people to participate in. More detailed information about people’s life histories and interests was available to staff to improve the quality of activities offered. People and their relatives were involved in the planning and reviewing of their care. People knew how to complain if they were unhappy about any aspect of their care and support and there was a system in place to manage complaints.

People, relatives and staff told us they felt the home was well managed. The registered manager and staff team had made a number of improvements since the last inspection. There were effective systems in place to monitor the quality of care being provided. People and staff were involved in identifying further areas for development and this feedback was used to drive improvement. The provider had notified us of incidents and events as

This inspection took place on 14 July 2016 and was unannounced. At the last inspection in August 2014, we found the provider was meeting all of the requirements of the regulations we reviewed.

The Elms is registered to provide accommodation for up to 13 people who require personal care and support. On the day of the inspection there were 12 people living at the home. There was a registered manager in post. 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 2008 and associated Regulations about how the service is run.

The provider had not carried out sufficient checks on new staff members. People, relatives and staff felt there were not enough staff to meet people’s care and support needs in a timely way. People told us they felt safe. People received care from staff that protected them from the risk of potential abuse. Staff were confident in reporting any concerns or suspected abuse. Risks to people were recorded and understood by staff. People were happy with the way they received their medicines, however systems used to manage medicines had not identified discrepancies in the receipt and administration of medicines.

Assessments of people’s capacity to make certain decisions had not always been recorded accurately. People told us they enjoyed the food but were not offered a choice at mealtimes. Staff received regular training and had the skills, knowledge and experience to meet people’s care and support needs. People’s consent was sought before care was provided. Staff were aware of people’s preferences and people with specific dietary requirements received appropriate food. People had access to appropriate healthcare according to their needs and staff responded without delay to changes in people’s health.

People were not always supported in a way that maintained their dignity. Staff knew people well and treated people with kindness. Staff had a good knowledge of people’s needs and preferences. People were involved in making decisions about their care and support. People’s relatives were welcome to visit the home at a time of their choosing.

People told us there was a lack of day to day activities available to them. People’s care was tailored to their individual needs and choices. Staff had a good understanding of people’s preferences and life histories. People felt able to express their views to the staff or the registered manager. There was a system in place to manage complaints.

People and relatives had been invited to give feedback about the service. Staff expressed mixed views about whether they felt listened to when they contributed ideas. The registered manager and senior staff carried out checks to monitor the quality of care provided, however, these audits had not identified the issues found at the inspection.

During this inspection we found a breach 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 the report.

A single inspector carried out this inspection on 26 August 2014. As part of this inspection we spoke with the provider, registered manager, deputy manager, a district nurse, members of staff and we reviewed information given to us by the provider. We met the people who lived at the home.

Below is a summary of what we found. The summary is based on our observations during the inspection, observations of people using the service, the staff supporting them and from looking at records. We used the evidence we collected during our inspection to answer the five questions.

Is the service safe?

From our observations and the information we saw in care plans, policies, procedures and audits, the provider's safety monitoring systems were robust. The staff training records showed that staff received regular training on safeguarding. Staff showed they had a clear understanding of their role in providing care and in safeguarding the people they supported. The staff demonstrated that they knew the people well and understood their support needs.

We saw evidence that when people lacked the capacity to make decisions on important areas of their lives, best interests, safeguarding and deprivation of liberty discussions had taken place. We saw the home had the support of the local advocacy service.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. We saw that all the people who lived at the home had a mental capacity assessment and there were no current safeguarding orders in place. The provider was reviewing the safeguarding requirements for all the people who live at the home in the light of the recent changes to the legislation at the time of our inspection.

Staff rotas showed that management had taken people's care needs into account when making decisions about the number of staff required and the skills and experience staff would need. The night time staffing levels and on call system showed that the provider had taken steps to ensure the staffing provision was safe.

We saw where issues of concern had been raised on a previous inspection which related to the storage and audit of medicines kept at the home and risk assessments. These issues had been addressed by the provider and the medicine management and risk assessment systems were safe.

There were systems in place to make sure that management and staff learned from events such as accidents and incidents, complaints, concerns and investigations. This meant that people were benefiting from a service that was taking on board lessons learnt.

Is the service effective?

We saw that people's care needs had been assessed and detailed care plans had recently been reviewed and updated. There was evidence that people and their families were involved in the assessments of their needs and care plan reviews as much as possible.

The staff we spoke with and activity plans we looked at provided evidence that people were supported to maintain active lives.

We saw evidence that people were supported by a wide range of health care professionals. This meant their health and welfare needs were being met.

Is the service caring?

We observed that staff supported each person in a way which met their individual needs. The staff showed warmth, consideration and respect for people. One member of staff we spoke with said, “I have worked here for many years and I really enjoy my work. I look after people as I would a family member”. Another member of staff said, “It is a good staff team here, we have worked together for many years and we try to make the place like home for the people who live here”. We saw that staff ensured people’s dignity was maintained at all times.

We spoke with one of the people who lived at the home, they said, “It is as good as it can be here. The girls listen to me, they are lovely”.

The registered manager and staff we spoke with told us they were committed to provide a good caring service to support and look after people. The staff we spoke with demonstrated that they were aware of potential risks, people's rights and their responsibilities.

Is the service responsive?

We saw the care plans and risk assessments had all recently been reviewed and were focused upon the current needs of the individual. The care plans contained detailed information about people's choices and preferences. The information showed that each person had an individual support plan which was adapted regularly to meet their changing needs. We saw that people’s health and support plans were regularly updated to reflect people’s changing health care needs.

There was evidence of regular support provided from health care professionals. This meant that people’s health and welfare was regularly reviewed and monitored.

The staff we spoke with said if they had any concerns, they could always talk with the managers and that they would always listen and address anything they raised. We saw that staff received regular training which equipped them with the knowledge and skills to meet people’s support needs.

Is the service well-led?

The home had a clear management structure in place. The provider, registered manager, deputy and the staff we spoke with were very knowledgeable about the people who used the service, changes to legislation and developments in care provision.

We saw on the staff rota that senior staff were on duty to give advice and support. We saw that there were systems in place to provide feedback to staff about changes and developments. The registered manager had ensured that a regular program of staff supervision was in place.

During our inspection we spoke with four people, three visitors, four members of staff and the manager. We looked at three people’s care records. There were 11 people resident at the home on the day of our inspection.

The care people received was reflected in their care plans. One relative told us, “They get individual attention”.

People were offered nutritious meals and snacks. People we spoke with were complimentary about the food served.

Medication audits and observations of staff administering medications were not undertaken. This meant that any medication errors were less likely to be identified.

We found that there were enough staff to ensure people’s needs were met in a timely manner. One relative told us, “There’s always staff in the lounge”.

Records were not always updated to reflect people’s latest care needs.

During our inspection we spoke with two people, two relatives, a visitor, three members of staff, the manager and looked at four people’s care records.

We found that people were supported in making day to day decisions about the care they received. People’s values and diversity were respected and promoted.

The care people received was reflected in their care plans and care was delivered in a safe and appropriate way. One relative told us, “It’s lovely in here, people are well looked after”.

Arrangements were in place to ensure that people were protected from harm. People said they felt safe living at the home. Staff demonstrated that they were aware of the importance of safeguarding people from abuse.

We found that staff were recruited in a safe way and correct checks were carried out to ensure their suitability to care for people. Staff were skilled in the provision of care to people. One person told us the home had, “Very friendly staff. They don’t ignore people, they rush to give assistance”.

The service had a clear complaints procedure which was advertised within the home. People told us they would feel confident in raising issues.

We spoke with people that use the service and they told us that they are involved in planning their care. We heard from people that “Staff have gone through care plan in the last six weeks” and” staff explained everything”. A number of people told us that the care provided by staff matched their needs as set out in their care plans.

We noticed some people were moved in wheelchairs without footrests by staff and we discussed this with people. They told us that they choose not to have footrests and they had been involved in this decision. This was confirmed by the manager and staff. We saw that this was written down in care records in addition to instructions for staff as to how to use wheelchairs differently so people’s feet would not become trapped underneath. We also saw staff carry out these instructions in practice.

We spoke with relatives of people that use the service who told us that staff “Treat (relative) with dignity and respect”. People we spoke to were positive about how staff treated them at the home, telling us the staff are friendly, and they were on first name terms. One person told us that other people living at the home could at times be “Trying” but that staff were very caring in response to this.

People told us that there is a range of stimulation available to them at the home. They told us about people from the community that come to the home to offer exercise or craft sessions. We also saw that staff were stimulating people during the time of our visit with music and throwing a soft ball around. We saw good interaction between people and staff. A relative told us that “Staff try really hard, had Valentines Day – cakes, they loved it”. People we spoke to told us that they can play games such as dominoes and one person said they were supported with their embroidery. We heard that the home has links with a local church, with people visiting to offer individuals spiritual support if needed. We heard a representative from the church is also involved in craft sessions at the home.

We saw and spoke with a number of people and saw that they were well presented, clean and looked content at the time of our visit.

People we spoke to said that they are satisfied with the way that they are cared for at the home, and that they feel safe. They told us that “Never no trouble with the staff if want something doing they do it”, and that when they needed assistance this was provided promptly, with carers always on hand. We also saw staff respond to requests for assistance from people promptly. One person said there was a slight delay on staff shift changes, although after these took place staff came and asked if they needed assistance. They told us that staff put them at ease. People told us that they felt safe as emergency buzzers were to hand.

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We spoke to people’s visitors and heard that they are offered hospitality when they arrive at the home. They also told us that they are invited to any events that take place at the home, this with the aim of encouraging their involvement. They said “Absolutely take very good care of (relative)“, “can relax because (relative) is in good hands always looks well presented, looks better here than at home, hair always nicely brushed, well looked after”. “Can’t speak to highly, cared for excellent, they care about the people they look after”, “They try to stimulate people”.

It was also said that people were “Looked after very good, couldn’t wish to get a better place, well run, never no trouble with the staff if want something doing they do it”. We heard that relatives of people that use the service are kept informed as to changes and in emergencies, such as after someone falls or is ill. They told us that appropriate outside medical help is always called.

People told us they liked living at the home and there were “no hard and fast rules” and they could follow their chosen routines. We also saw and heard from people that when they wished they could spend time in their room or any communal area in the home.

People said to us at the time of our visit that they feel safe at the home and have no concerns about their safety. People’s relatives that we spoke to made similar comments, two saying they had never had any concerns.

People told us that they knew how to complain and said that “Staff at any level very approachable”. Some said that they could talk any matters through with the manager. We heard from some people that if they were concerned about their safety they knew to approach social services.

Some people living at the home said that other people did on occasion become upset, but said to us that staff are good at dealing with type of situations.

We heard from Wolverhampton Social Services there was an allegation that the heating in the home was turned off at night even in winter, leading to residents getting frequent colds. We spoke to a number of people living at the home and all told us that there were no problems with the heating in the home, and that they were warm enough day and night. The one exception to this was where one person said there was an occasion when they had been cold and when mentioned to staff they had ensured that the heating was on. Another person told us that “No issues re heating, been a bit warm when come in”

People we spoke to expressed a high level of confidence in the staff team and told us that they felt they were competent. People told us that the home is “well run”, “Couldn’t wish to get a better place, well run” and that they have “always found the place good”