Archived: Leonard Elms Care Home

The Leonard Elms Care Home is a care home providing personal and nursing care to up to 37 people. At the time of our inspection, 37 people were living at the service. The service specialises in caring for people who are living with dementia. The Leonard Elms Care Home is in a rural location. Accommodation is provided in a purpose built new wing, which is attached to the older part of the property.

People’s experience of using this service and what we found

People were protected from the risk of abuse and harm because the service assessed, monitored and managed the risks associated with their care. Information was recorded and shared appropriately to enable staff to help people get the care they required. Records were accurate, complete and up to date.

Staff understood people’s health and wellbeing needs and referrals were made to specialist services as required. People were supported by staff who followed systems and processes to manage medicines safely. We were assured that people were protected by the prevention and control of infection. The living environment and equipment were regularly checked to reduce and manage risks.

There was a high level of staffing to ensure people could be supported safely with as little restriction as possible. Staff were safely recruited and received a wide range of training opportunities to ensure they followed current best practice.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff understood the best ways to communicate with different individuals and showed kindness and compassion when interacting with people. People had opportunities to take part in activities that met their needs and were meaningful to them.

There was a supportive and caring culture where people’s individuality and the importance of family was promoted and valued. The management team were visible and led by example. Staff felt supported and respected and enjoyed working at the service. Feedback from people, relatives and professionals was positive.

Governance processes were effective and monitored performance, kept people safe and encouraged the provision of good quality support. Actions were taken when shortfalls were identified.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 30 April 2019).

At the last inspection we found a breach of regulations relating to medicines and equipment safety. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

At our last inspection we recommended the service implemented effective systems to ensure care plans were completed and kept up to date. At this inspection we found care plans were in place for everyone living at the service, and these were up to date.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 25 and 27 February 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe, responsive and well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Leonard Elms Care Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Leonard Elms Care Home is a care home providing nursing and personal care for up to 37 people. The service had 32 people living at the service at time of the inspection. The service was laid out over two floors, with a courtyard in the centre of the building.

We found the following examples of good practice

The provider had an outbreak of Coronavirus within in the home. The registered manager had regular contact with Public Health England and the local commissioning team to monitor the outbreak.

The outbreak had impacted significantly on staffing levels. However, staffing numbers were being managed. Adjustments were made to support staff as they returned to work. For example, shorter shift lengths.

Staff had received training in infection control, including how to use personal protective equipment (PPE). The service had a one-way system in place and stations for donning and doffing PPE. This is the putting on and taking off of PPE. Staff we spoke with were clear on the procedures and systems in place. The outbreak had highlighted the need to use appropriate PPE when there was a risk unintended contact from people living in the service may occur.

Due to the recent outbreak the provider did not have visitors coming into the home, except in exceptional circumstances, this was to help contain the virus. Systems were in place when people entered the home such as temperature checking, a COVID-19 declaration form and a handwashing station.

At the time of our inspection, the provider was not admitting people to the service because of the outbreak.

The registered manager ensured regular testing was carried out, weekly for staff and monthly for people. People could choose whether they wished to have a COVID-19 test. Where people did not have the capacity to make a decision around COVID-19 testing, best interest decisions were made in line with guidance. Staff had a good understanding and knowledge of the Mental Capacity Act (2005) and ensured people’s choices and wishes were respected.

Further information is in the detailed findings below.

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.

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 correctly or monitored to manage their health conditions. At this inspection, we found improvements had been made. Staff worked together as a team to ensure people received consistent person-centred care. The staff were well trained and knew how to support people effectively. They understood people's physical, mental health, social and cultural needs and ensured they received a personalised service. For example, staff assisted people to move safely, make choices, and have their medicines when they needed them.

We have made a recommendation about the detailed recording of support for people whose behaviour challenges the service

At our previous inspections, we found that the provider did not have effective systems and processes for identifying and assessing risks to the health, safety and welfare of people who use the service. Their audit systems had not identified that the continued breaches of the regulations had failed to be sufficiently rectified. At this inspection, we found that improvements had been made, as quality assurance systems and process were now in place to monitor the service and drive forward improvements. Following the providers action plan, required actions were completed in a timely manner and lessons learned were shared with staff to help improve the service.

People felt safe at the service because the staff were competent and caring and the environment secure. Relatives said staff were vigilant about people's safety and prevented or minimised the risk of falls.

Staff protected people from harm and knew whom to contact if they had concerns about a person's wellbeing.

There were enough staff at the service to meet people's needs. The names of staff on duty each day were displayed on a wall so people and their relatives could see who they were.

The staff employed were suitable and safe to work with people using care services.

People told us that the food was good, they had a choice, and there was enough food available for them. Menus were based on healthy eating choices and people's dietary needs and preferences. Mealtimes were relaxed and staff socialised with people while assisting them with their meals. Staff encouraged people to drink and remain hydrated.

Staff supported people to maintain good health and access healthcare services in the local community when they needed to. They understood people's healthcare needs and knew when to refer them for specialist support. Relatives said staff kept them informed about their family members' health and communicated any concerns quickly.

Staff knew how to support people if they needed end of life care and understood their roles in providing comfort, mouth and other types of care, and pain relief medicines where necessary.

There were items of interest and reminiscence in the communal areas and corridors following different themes including gardens and the seaside. All areas were clean, fresh, and hygienic.

The staff were caring and understood the importance of treating people with dignity and respect. They took the time to sit with people and chat to them about the things that were important to them such as their families and the things they liked to do. People's relatives and friends could visit at any time and were made to feel welcome.

People told us that if they had any complaints they would tell one of the staff on duty or the manager. The service's complaints procedure was displayed at the service and people were given a copy of this when they began using the service.

People were encouraged to participate in both one to one and group activities depending on their preferences. The service's activity organisers planned activities based on people's choices and were available over a seven-day period.

People and relatives told us the service was well led and the staff provided good quality care. Staff told us morale at the service was high, communication good, and teamwork effective. The atmosphere at the service was positive. The provider had systems in place to quality assure the service and help ensure a high standard of care and support was provided.

Significant Improvements have been made since the previous inspection. We found no breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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. At this inspection, we found sufficient improvements had been made. Where any form of abuse was suspected or reported by a third party the provider took appropriate action such as undertaking an internal investigation and making a referral to the appropriate body, such as the local authority safeguarding team. This included notifying CQC.

Appropriate arrangements were in place for reporting and reviewing accidents and incidents. This included auditing all incidents to identify any particular trend or lessons to be learned.

Staffing rotas viewed demonstrated that staffing levels were maintained in accordance with the assessed dependency needs of the people who used the service. New staff undertook an induction and mandatory training programme before starting to care for people on their own.

Relatives were welcomed to the service and could visit people at times that were convenient to them.

Staff felt well supported by the manager. The manager held a regular programme of staff meetings to advise them of operational issues and actions required.

People and their relatives also spoke highly of the manager and the provider. People were encouraged to provide feedback on their experience of the service.

Although some improvements had been made since the previous inspection this is the fifth inspection that the provider has failed to fully meet all the regulations. Since the previous inspection in February 2017, there have also been repeated breaches of the same regulations. These include: safe care and treatment; need for consent; person centred care; and good governance.

The provider did not have effective systems and processes for identifying and assessing risks to the health, safety and welfare of people who use the service. Their audit systems had not identified that the continued breaches of the regulations had failed to be sufficiently rectified.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We are currently considering the action we are taking.

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 safeguarding. Staff knew what action to take if they were concerned about the safety or welfare of an individual. However, systems put in place since the last inspection to ensure all incidents were correctly reported had not worked. External parties such as the local authority safeguarding team were not being informed of incidents which placed people at risk of harm. The recruitment process still did not always follow good practice. This meant people were being exposed to risk from staff who had not had the correct checks conducted by the provider.

People who lacked capacity did not always have the correct process followed for each decision made on their behalf. When the management and staff had decided to prevent people leaving the home for their safety the correct processes had not always been followed. As a result, people did not have their right to make choices respected.

The registered manager and provider had not followed their legal obligations to notify CQC of incidents such as when accidents had happened which placed people at risk of being hurt. The registered manager and provider regularly met to discuss what improvements needed to be made. Some new clinical audits had been started. However, the systems were not identifying all shortfalls in the home. Where some shortfalls had been identified, actions were not always taken to ensure improvement had been made. People knew how to complain. However, systems in place to manage the complaints were not always being followed to provide people with a timely response.

Most people had updated care plans because a senior member of staff was overseeing this process. Where care plans had been updated there was some evidence of people or relatives being involved. However, not all care plans had a person centred approach or contained information to ensure people’s health and care needs were met. They had not always been updated when systems to deliver care or keep people safe had changed. Staff supported people to see a range of health and social care professionals to help with their care.

People had a choice of meals, snacks and drinks. Alternative options were provided if people did not like what was served. Choices were offered in a way people could communicate their preference.

People and their relatives thought staff were kind and caring. We observed mainly positive interactions. However, there were periods of time when people did not receive interactions from staff. The privacy and dignity of people was respected most of the time and people were encouraged to make some choices throughout their day. There were occasions when people’s doors were left open by cleaners and choices had not considered people’s preferences.

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. We are currently considering the action we are taking.

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 correct process had not always been followed for each decision. As a result, people were at risk of their human rights being breached. When they had decided to prevent people leaving the home for their safety the correct processes had been followed.

The registered manager and provider had not followed their legal obligations to notify CQC. The registered manager and provider regularly met. There were now some completed audits which identified shortfalls. However, the systems were not identifying all shortfalls in the home or where some had been identified, actions were not taken in a timely manner.

The provider was in the process of ensuring all care plans had been completed on their new electronic system. Where care plans had been updated there was evidence of people or relatives being involved and good detail for some people. However, not all the care plans had a person centred approach or contained information to ensure people’s needs were met. This meant people were not central to their care and decisions they made for themselves or that were made for them.

Staff supported people to see a range of health and social care professionals to help with their care. But sometimes the home had not identified when people who needed to see these professionals. Staff supported and respected people’s choices and they knew how important this was.

People and their relatives thought staff were kind and caring. We observed mainly positive interactions. But there were times when staff were only communicating with people to fulfil tasks. 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 provider demonstrated a good understanding of how to respond to complaints.

The overall rating for this service is ‘requires improvement’, but the safe domain remains 'inadequate' so the service remains in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We made a recommendation the provider reviews national guidance on catering and keeping records for people who have specific dietary needs.

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

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.

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.