We carried out an unannounced inspection of The Elms Nursing Home on 21 and 24 May 2018.

The Elms Nursing Home 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 Elms Nursing Home is registered to provide accommodation for up to 48 people. The home provides both personal and nursing care support to older people including those living with dementia. The home also provides short term rehabilitation support for people.

At the time of the inspection the home accommodated a total of 37 people. Accommodation was arranged over three floors with lift access to all floors. There were several communal areas and places for people to sit quietly and meet with their families or friends. There were accessible outside spaces for people to access. There were also small bungalows in the grounds where some people lived. However, we were told that the home does not provide any regulated activity to the people living in the bungalows so these were not considered as part of this inspection.

There was a registered manager who was present throughout the inspection. 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 of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

This service was last inspected in November 2015 when we found that the provider had not ensured that there were detailed person-centred care plans for people. At this inspection we found that although some action had been taken to address this issue, additional improvements were required.

At this comprehensive inspection we found six breaches of regulations. Failures to provide safe care, person centred care, provide enough staff to meet people’s needs, good governance and failing to act in accordance with the Mental Capacity Act 2005 were issues we identified during this inspection.

Quality assurance systems were not sufficient to monitor and review the quality of the service which was provided. These had not been used effectively to identify concerns we found or drive improvement in the service.

There were not enough staff to meet more than people's basic personal care needs. Staff were task orientated and did not always engage with people and support them to be involved in meaningful activities.

Care plans were not consistently person centred and contained conflicting information. Risk assessments that related to people's health and safety did not ensure that all risks were effectively assessed. This exposed people to a risk of neglect and unsafe or inappropriate care or treatment.

Records of the assessment of people's ability to make some informed decisions had been undertaken. However, these had been recorded as generic decisions and were not decision specific. The principles of the Mental Capacity Act 2005 were not being applied in respect of best interest decisions to provide care or use least restrictive practices. This led to people being unlawfully deprived of their liberty.

Staff had received training to meet people's needs; however, this had failed to ensure that safeguarding processes were followed.

Peoples' wellbeing was not promoted due to a lack of person centred activities. We observed, and people told us, that activities were limited and did not take place as detailed in the schedule of activities.

People had mixed views about the food and choices were not offered in an effective way for people living with dementia.

We received some positive feedback about the staff and their approach with people using the service. However, some staff showed a lack of consideration for people's dignity, for example in the lack of communication

We spoke with four people who used the service and three relatives. They all said they were very happy with the level of care provided and staff understood their needs and sought their consent before providing any care. One person said staff “know me well enough now and know what I like. If I don’t feel like doing something I don’t have to do it”. A relative told us “This is a wonderful home with wonderful staff. There is nothing that is too much trouble for them”.

We looked at ten care plans and saw they were individualised and included the necessary information to inform staff as to the specific care people required. We saw these were reviewed on a regular basis. We observed care in the communal areas of the home and saw staff generally interacted with people in a positive way. One person said “staff are ever so helpful. They pop in for a quick chat and check I am alright”.

We found the home had effective systems in place to protect people from abuse. One person said “I do feel safe here. The staff would never let any harm come to me”. A relative told us “I am so grateful he is here. I can relax knowing he is well looked after”. People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. We found the provider had an effective quality assurance system and they sought the views of people who used the service and their families through regular surveys.

We spoke with people who lived at the home. We also spent some time in the home’s main lounge observing people and the way they were cared for.

We spoke with visitors and met with external professionals who were visiting the home at the time of our inspection.

External professionals stated that they had no concerns about how people’s health and care needs were met. Professionals were complimentary about the way the service met people’s physical and cognitive needs.

Everyone we spoke with confirmed that people’s privacy and dignity were maintained at all times and that people were able to make day to day decisions such as what time they got up and how and where they spent their time.

We observed that people were enjoying their lunch time meal and those able to respond told us meals were good and that alternatives were provided.

People said that they had no concerns about how their personal care needs were met. They also told us that if they were unwell then staff would contact a doctor for them. They told us that staff were available when people needed them and knew what care they required.

Visitors said that they felt staff were available whenever their relatives needed assistance. They also said that staff were very pleasant and had the necessary time to meet people’s needs.

People and relatives said that if they had any concerns or complaints they would raise these with the manager or provider. Nobody had any concerns when we spoke with them.

The Elms Nursing Home is registered to provide accommodation for up to 48 People. The home provides both personal and nursing care support to older people including those living with dementia. The home also provides short term rehabilitation support for up to five people. At the time of the inspection the home accommodated a total of 45 people.

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.

The inspection was unannounced and was carried out on the 03 and 05 November 2015.

There were appropriate systems in place for the management of medicines. However, there was no guidance to support staff with the administration of ‘when required’ (PRN) medicine. We pointed this out to the registered manager and by end of our inspection this guidance was included in people’s care plans.

Care plans were generic in style and focussed on people’s clinical needs. However, they did not identify how staff should support people on an individual basis.

People and their families told us they felt the home was safe. Staff and the registered manager had received safeguarding training and were able to demonstrate an understanding of the provider’s safeguarding policy and explain the action they would take if they identified any concerns.

The risks relating to people’s health and welfare were assessed and these were recorded along with actions identified to reduce those risks in the least restrictive way. They were personalised and provided enough information to allow staff to protect people whilst promoting their independence.

People were supported by staff who had received the appropriate training and professional development to enable them to meet their individual needs. There were enough staff to meet people’s needs and to enable them to engage with people in a relaxed and unhurried manner.

Staff sought verbal consent from people before providing care and when appropriate followed legislation designed to protect people’s rights and ensure decisions taken on behalf of people were made in their best interests. We found the home was meeting the requirements of the Deprivation of Liberty Safeguards.

Staff developed caring and positive relationships with people, were sensitive to their individual choices and treated them with dignity and respect. People were encouraged to maintain their family relationships. People, and where appropriate their families, were involved in discussions about their care planning, which reflected their assessed needs.

People were supported to have enough to eat and drink. Mealtimes were a social event and staff supported people in a patient and friendly manner.

There was an opportunity for people using the service and their relatives to become involved in developing the service and they were encouraged to provide feedback on the service provided. They were also supported to raise complaints should they wish to.

People and their families told us they felt the service was well-led and were positive about the registered manager who understood the responsibilities of their role. The providers were fully engaged in the development of the home and had developed links with external organisations and professionals to enhance the quality of the service provided. Staff were aware of the provider’s vision and values, how they related to their work and spoke positively about the culture and management of the service.

There were systems in place to monitor quality and safety of the service provided. Accidents and incidents were monitored, analysed and remedial actions identified to reduce the risk of reoccurrence.