The inspection took place on 24 April 2018 and was unannounced.

Our last inspection of this service was on the 15 February 2017 and we found concerns relating to regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found that the provider was not ensuring that the premises were safe to use for their intended purpose, because a stair gate posed an avoidable risk to service users. Also there was a lack of oversight and scrutiny of the quality and safety of the home .The overall rating for the service was Requires Improvement. At this inspection, we found significant improvements had been made to the service and found the service to be ‘Good’ in all of our key questions; safe, effective, caring, responsive and well led.

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 key questions in safe and well led. At this inspection, we found that the provider had addressed the height of the stair gate to avoid risk to service users. Regular medication audits were taking place and the proprietor was making monthly visits to the service and providing a written report on the quality and safety of the service.

The Royal Elms is “care home” providing care for up to 26 people in the Newton Heath area of Manchester. People in care homes received accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. There were 22 people living at The Royal Elms on the day of inspection.

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.’

People told us they felt safe living at The Royal Elms.

There was no Legionella risk assessment in place although the water temperature checks and flushes of outlets were regularly being completed internally. We recommended that the service follows the national Health and Safety Executive and Department of Health guidance for controlling Legionella in healthcare settings.

Staff members received training in protecting vulnerable people from abuse and all staff said they felt confident that they could raise any concerns.

Staff members were recruited safely and received induction appropriate to their role.

Medicines were stored and administered safely and staff members routinely had their competence assessed for the safe administration of medicines.

Staffing levels were satisfactory and people were not rushed.

Staff members had completed training appropriate to their role and responsibilities. They received regular supervision and were able to attend staff meetings.

Long corridors within the home enabled people who liked to wander, to do so in a safe environment. There was dementia signage used across the home and the décor of the home was suitable for people living with dementia.

People were able to choose from a menu which meals they wished to eat. Staff were aware of who had what type of diet and who needed a soft or fork mashable diet.

The service was working within the principles of the Mental Capacity Act (2005). Appropriate capacity assessments had been completed and referred for deprivation of liberty safeguards (DoLS) in a timely manner.

We observed staff to have kind, caring and dignified interactions with people living at The Royal Elms. There were appropriate humorous jokes shared between staff and people which were well received.

People who were anxious were well support, reassured and spoken with in a calm manner to prevent their anxiety escalating.

Staff members were knowledgeable on the differ

The Royal Elms Care Home is a residential care home in Newton Heath, north east of the centre of Manchester. It can accommodate up to 25 people. At the date of this inspection there were 22 people living in the home.

This inspection took place on 15 February 2017 and was unannounced, which meant the service did not know in advance when we were coming. The previous inspection had taken place in October 2015, when the service was rated as “requires improvement”. At that time, we found breaches of four regulations. These related to care records not being updated, consent to care not being properly obtained, issues regarding medicines and infection control, and quality monitoring systems. We asked the provider to submit an action plan, which we received on 21 December 2015. At this inspection we checked to see whether those actions had been completed. Further details are given in the main body of this report.

The Royal Elms had a manager in post since 2008, who had been registered with the Care Quality Commission since 2010. 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.

People told us they felt safe living in The Royal Elms. The building was adapted for the needs of people with reduced mobility. We considered that the stairgate at the top of one staircase posed an unnecessary risk. This was a breach of the regulation relating to safety.

Improvements had been made since our last inspection in relation to the storage of medicines. A sink had been installed in the medicines storage room. Medicines were administered safely.

Risk assessments were completed relating both to care and trips outside the home.

Staffing levels were acceptable. At the date of this inspection there was no cook and the registered manager and other staff were filling in.

Staff understood about safeguarding. Correct processes were followed when recruiting staff.

The home was kept clean and regular checks were made to restrict infection from spreading.

The home was protected against the risks of fire, and the building was well maintained.

New staff and existing staff received appropriate training. New staff were not yet following the Care Certificate. Supervision and appraisals were taking place to support staff.

Staff had received training in the Mental Capacity Act 2005 (MCA) but there was scope for bringing this up to date. Consent forms were used to record that people consented to care, but when a person lacked capacity to consent, the form implied incorrectly that relatives could consent on their behalf.

Applications were made under the Deprivation of Liberty Safeguards (DoLS). One application had been made for someone nearing the end of life, which may have been inappropriate.

People liked the food. The lunchtime dining experience was enjoyable.

People’s weight was recorded regularly. People had access to a range of healthcare professionals.

The downstairs had been repainted in colours considered suitable for people living with dementia.

People living in the home and relatives told us they thought the staff were caring, and encouraged them to be independent. Staff were patient and knew the people in the home well. People were dressed in a dignified way. There was one exception but this was that person’s choice.

Confidentiality was respected. The home was prepared to meet people’s needs as they approached the end of life.

Care plans were thorough. They contained handwritten plans for each aspect of care. A new style was being introduced with typewritten plans, which were a little easier to follow. People’s life history was recorded, where known, which enabled staff to engage with people.

There had been no formal complaints recently. People were able to ap

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

This is a summary of what we found-

Is the service safe?

We looked at the training matrix and saw staff members had competed training related to the safeguarding of vulnerable adults. We spoke with two staff members and they were knowledgeable about their roles and responsibilities which helped ensure people who used services had their safety protected.

Various safety checks had been completed which included hoists and slings in December 2013. These checks and audits helped ensure the safety of people who used the service.

Deprivation of Liberty Safeguards (DoLS) become important when a person is judged to lack the capacity to make an informed decision related to their care and treatment. We saw an application had been made for a DoLS in January 2014 and the required paperwork had been completed appropriately. At the time of our inspection, no person who used the service was subject to a DoLS.

Is the service effective?

We saw evidence that an advocacy service was available for people who used the service. This meant people could access further support when they needed it which helped ensure their care needs were met in accordance with their care plans.

People`s care needs were assessed with them. Care plans we saw had been signed by the person who used the service or their representative. This showed they were involved in creating their care plans.

Is the service caring?

We spent time in communal areas and observed how staff members provided care and support to people who used the service. We saw staff provided care in a patient and unhurried manner.

People who used the service and, when possible, family members, attended meetings and completed regular surveys. We saw minutes from the meetings and any shortfalls had been addressed.

Is the service responsive?

People who used the service took part in a range of activities both inside the home and within the local community. Regular church services were held at the home which meant people had their religious needs met.

We saw evidence that an appropriate complaints system was in place at the care home. This helped ensure people would have any complaints investigated thoroughly and action taken if necessary.

Is the service well led?

The provider had policies and procedures in place that monitored the quality of service being provided to people who used the service. This meant the service continued to improve.

The care home worked well with other agencies which included GPs and community nurses. This helped ensure people received care and support when they needed it.

This was a scheduled inspection during which we also followed up on non-compliance found at the previous inspection. We saw that record-keeping had improved, which assured the manager that the home was clean and people were safe.

We spoke with most of the 24 people who lived in the home, who all spoke positively about the home. People looked comfortable and clean.

People told us that they had "no complaints." "Staff listen", "everybody's good" and "[the staff] are really good". One person said that when they came into the home they could not walk, but staff "helped me with standing up" and now they could walk to the toilet and back. "I do as much as I can myself".

Staff were aware of people's individual needs and provided care according to their care plans, which were reviewed regularly and were up to date. We saw regular involvement of other professionals, such as doctors, district nurses or a chiropodist. Staff responded promptly to incidents, to keep people safe. There were enough staff available to meet people's needs.

People told us that they enjoyed the meals. Kitchen staff were able to accommodate special requests. We noted that the kitchen was spacious but worn. The care home was located in a large converted home with red or patterned carpets and cream walls. Some of the bedrooms had been recently re-decorated, and the manager had plans for re-decorating other parts of the home to improve the service.

People told us that the staff were "fantastic." One person said they wanted to be at home but that while they were here: "it's okay. The staff are fantastic." We saw that people looked clean and well. We saw that people interacted positively with staff and other people using the service. We spoke with relatives of a person using the service who said that their relative "likes everybody" and is comfortable and "well looked after." They told us that the staff "couldn't do more" to keep this person safe while still respecting this person's wishes.

We saw that staff asked for people's consent and acted in accordance with people's wishes. We saw that the provider asked for people's opinions in meetings and through surveys. We saw that this had resulted in changes to the service. We saw that people’s complaints were fully investigated and where possible, resolved to their satisfaction.

We saw that the provider had an effective system in place to recruit staff. We saw that the provider had a system in place to maintain cleanliness, although this was not always implemented consistently. Cleaning records were not accurate and fit for purpose. We saw that people's care records were well-organised and clear.

We received no comments from people during this review. The purpose of this review was to monitor and evaluate improvements made following our last review of the service in September 2011.

People living in The Royal Elms told us that they felt supported and well cared for and that care workers understood their needs and how to meet them. We were told that things that were important to people such as their rights to privacy, dignity and respect were maintained by the staff working in the home and any concerns or worries would be listened to and addressed quickly and appropriately. People appeared comfortable in their surroundings and where able, told us that they were happy with their daily lifestyles including the choice of food available, the environment they lived in and the overall standard of the service they received.

The inspection took place on 28 and 29 October 2015 and was unannounced. At the last inspection, in April 2014, the service was judged compliant with the regulations inspected.

The Royal Elms is a care home offering accommodation and care for up to 26 older people. The home is situated in the Newton Heath area of Manchester. Bedrooms are situated on both the ground and first floor of the home. There are gardens to the rear of the home and limited parking at the front of the building.

The service has a registered manager who has been registered with the Care Quality Commission since March 2013. 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 arrangements for handling and administrating medicines required some improvements to ensure it was safe and people received their medicines as prescribed. We found the drugs store room needed some attention to ensure it was suitable for the storing of medication. There was no suitable arrangement for hand washing to prevent cross infection. Protocols to manage ‘as required’ medications (PRN) were not sufficiently detailed. You can see what action we told the provider to take at the back of the full version of the report.

Procedures in relation to recruitment and retention of staff were robust and ensured only suitable people were employed in the service. We found staff were mostly skilled and experienced staff and there was a programme of training. However some staff had not received up to date dementia awareness training. Supervisions were taking place regularly however; staff had not received their appraisal which gives staff an opportunity to discuss their development. You can see what action we told the provider to take at the back of the full version of the report.

Staffing levels were adequate although from our observations we found staff were only able to meet the basic needs of people. We saw very little interaction with people and conversations were mainly in relation to the care tasks that staff were undertaking. Sufficient domestic hours should be deployed to help control and reduce the risk of infection.

The manager was aware of the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). There were policies and procedures in place and key staff had been trained. This helped to make sure people were safeguarded from excessive or unnecessary restrictions being place on them.

The requirements of the Mental Capacity Act 2005 were in place to protect people who may not have the capacity to make decisions for themselves. The Mental Capacity Act 2005 (MCA) sets out what must be done to make sure that the human rights of people who may lack mental capacity to make decisions are protected, including balancing autonomy and protection in relation to consent or refusal of care or treatment. We found the registered manager was following the guidance and had made one referral to the supervisory body to restrict one person’s liberty. This was applied for to prevent the person from harm.

We were only able to speak with two people who used the service. This was because most of the people living at the home were unable to communicate with us in a meaningful way as they had limited mental capacity. Therefore we carried out observations throughout the inspection. We also spoke to visitors to the home during the inspection to gain their views of the service.

People’s physical health was monitored as required. This included the monitoring of people’s health conditions and symptoms so appropriate referrals to health professionals could be made. We saw evidence that the home worked closely with GP’s, district nurses, community psychiatric nurses, dieticians and tissue viability nurses. However we found one care plan had not been followed to obtain a urine sample for a person when the GP had requested it. The registered manager and deputy manager were unaware that the sample had not been obtained.

We found staff approached people in a kind and caring way and we saw people were respected and treated in a dignified manner. However, staff spent most of their time on practical tasks and physical care and there was sometimes little interaction or conversation between staff and people using the service.

Staff told us they felt supported and they could raise any concerns with the manager and felt that they were listened to. Relatives told us they were happy to raise any concerns directly with the registered manager.

We found the systems in place to monitor and improve the quality of the service were ineffective. The registered provider told us that they visited the home once or twice a month and spoke to the registered manager on a regular basis but they did not produce a report which could demonstrate how progress was made with any actions required. The registered manager told us that she regularly checked care plans to ensure they were up-to-date but did not record any actions. Some care plans we looked at were not up-to date so the monitoring system was not effective. The registered manager told us that people were consulted about their views at regular intervals. You can see what action we told the provider to take at the back of the full version of the report.

The service user guide told us that the home specialised in dementia care. However, the environment was not dementia friendly in the use of colours furnishings and carpets. Signage was poor which meant people would find it difficult to orientate themselves around the home. Parts of the environment were not fit for purpose and could cause injury to people who used the service. You can see what action we told the provider to take at the back of the full version of the report.

We saw no evidence of personalised features by the entrance to bedrooms to help people find their own rooms. Bedrooms had numbers on the door that were difficult to read in the light available and had no personalised distinguishing features that would be routinely found in a dementia care home that has been thoughtfully organised to meet the needs of people living with dementia. There were no handrails on the corridors on the first floor which made it difficult for people to move around independently.