Archived: Elmwood Nursing Home

At our last inspection on 2 August 2016 we found three regulatory breaches which related to staffing, the need for consent and quality assurance. Accordingly, the service was rated ‘Requires improvement’. Following that inspection the provider wrote to us with their action plan which set out what they would do to meet these regulatory requirements.

Elmwood Nursing Home is a purpose built residential home that provides nursing care and support for up to 60 older people, most of whom were living with dementia. At this inspection 51 people were living at the service.

The service did not have a registered manager in post at the time of the inspection although the new manager had started the registration process. 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’s consent was not always obtained. Care records contained Best Interests decisions which stated that people were unable to communicate or make decisions whilst their assessments and care plans stated they could communicate and make decisions. We found that where a supervising authority had stated a person had capacity to make a decision and that a deprivation of their liberty had not been approved; the service had not amended care records to reflect this. Staff received training, appraisal and supervision but records of supervision meetings did not reflect what was discussed.

People were at risk of not having their needs safely met overnight because there were insufficient staff numbers available to provide care, support and supervision. People and staff were at risk of harm because care records contained inaccurate information about people’s assessed mobility needs. Care records stated that people required one member of staff to support them to transfer whilst their assessments stated two staff were required to do so safely.

People’s medicines were administered, recorded and stored appropriately. Staff were recruited using robust procedures that ensured they were suitable to deliver care. People at risk of choking, pressure ulcers and undernourishment had detailed assessments and care plans in place to support them. People were supported with nutritional assessments and received the support they required to eat and drink safely. People enjoyed the nutritious meals they received and healthcare professionals supported people whenever they were required.

People and relatives told us that staff were caring and kind. People and staff shared positive relationships. People’s independence and dignity were promoted and their privacy and confidentiality were maintained.

Care records did not reflect person centred care. There was significant replication of information between people’s care records which included the exact same wording for people’s preferences. This included identical information about people’s stated final wishes.

A range of activities were available for people to participate in support was available to prevent people from becoming socially isolated. Communication with relatives had been improved with the introduction of relatives meetings and the role of keyworker who liaised with them on an on-going basis. People’s cultural and religious needs were identified and met and the service created opportunities for people to experience cultures other than their own. Complaints were addressed in line with the provider’s policy which included a written response within the stated timeframe. The provider actively sought the views of relatives and people through meetings and surveys and responded to the feedback it received.

People did not receive a service were the quality assurance processes were robust enough to identify and rectify failings in care records. We found information had been duplicated across a number of people’s care records which resulted in inaccurate information about people’s needs, care and support.

The new manager had made a number of improvements to the service including redecorating the building, improving communication with relatives and increasing activities. The manager worked collaboratively with other agencies to improve the service people received.

During this inspection, we identified a number of continued breaches 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 this report.

At our last inspection in March 2018 we found Elmwood Nursing Home to be on breach of five regulations of the Health and Social Care Act. These breaches were in relation to safe care and treatment; dignity and respect; staffing; consent and poor management. As a result of these findings we rated the service ‘Inadequate’ and placed Elmwood Nursing Home into ‘Special Measures’. At this inspection we found the service to be in continued breach of all five regulations and identified breaches of two further regulations. The additional breaches were in relation to protecting people from abuse and notifying CQC of incidents were people had been harmed.

Elmwood 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 service accommodates up to 60 people across three floors. 35 people were living in the service at the time of the inspection.

The service did not have a registered manager in post. However, a new manager had been appointed at the service and they were in the process of registering with CQC. 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 continued to be at risk of unsafe care and treatment because care records continued to contain inaccurate information about people. The incorrect details in care records included the wrong textures for food and consistencies of drinks for people who were at risk of unsafely swallowing. Care records showed that people were at risk of pressure sores worsening because dressings were not changed as frequently as prescribed. People were not adequately safeguarded from abuse and improper treatment because the provider failed to notify the CQC and Local Authority when people had been harmed. This prevented the appropriate level of investigation from being carried out. The provider continued to deliver nursing care to people without directly employing nurses to manage care to people on each floor.

People were not always treated in line with the principles of the Mental Capacity Act 2005. Care records continued to provide staff with incorrect information about people’s capacity and ability to communicate. Staff were not receiving regular supervision or appraisal but they did receive on-going training. People accessed healthcare professionals whenever they needed to and the service provided people with nutritious meals.

Staff did not always demonstrate care when supporting people. People who were living with dementia were left for lengthy periods in their wheelchairs in the centre of communal areas in view of others, instead of being transferred to armchairs alongside them. When these and other people became upset they did not receive the care and reassurance they required. In general, people’s dining experience continued to be poor. People were left unattended for long periods at dining tables without explanation and staff spoke very little to people as they served and supported them. However, staff providing one to one assistance to enable people to eat, did so with kindness and sensitivity.

People’s care records, whilst more personalised than those we reviewed during previous inspections, continued to contain inaccurate information. When people’s needs changed they were not always reflected in care record and daily care records were not always completed appropriately. The service was responsive and creative in meeting people’s spiritual needs and people identified to be approaching the end of their lives continued to be supported compassionately.

The service continued to be inadequately managed. This was the fourth consecutive inspection at which we have found the provider to be in breach of regulation related to good governance. The provider organisation had failed to improve the overall quality of service people received. This prevented people from receiving their care and support in line with fundamental standards. Quality assurance audits and processes identified a number of the issues we found during our inspection but failed to address shortfalls. This included a failure to improve people’s dining experience and to make safeguarding referrals.

The overall rating for this service is 'Inadequate' and the service is therefore 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.

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.

During this inspection, we identified six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of this report. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

At our last inspection in September 2017 we identified breaches of regulations relating to safe care and treatment, the need for consent, staffing, person centred care and good governance. We rated the service ‘Requires Improvement’ and served the provider with warning notices for the breaches relating to safe care and treatment, the need for consent and good governance. We told the provider they must be compliant by January 2018.

Elmwood 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 service accommodates up to 60 people across three floors. 45 people were living in the service at the time of the inspection, one of whom was in hospital.

The service did not have 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 continued to be at risk of unsafe care and treatment. Care records contained inaccurate information about people and the support they required to mobilise. Risks to people were increased by the high use of agency staff who did not know people and who were guided by inaccurate care records. Monitoring records for people at risk of dehydration were poorly maintained creating the risk that they may become dehydrated. Pressure relieving mattresses were not always set correctly placing people at risk of developing pressure ulcers.

People’s rights under the principles of the Mental Capacity Act 2005 were not always upheld. Some people with capacity and the ability to speak had best interest assessments in place which stated the opposite. People’s dining experience was chaotic. There was no visible coordination of staff during people’s lunch. Some people sat uncomfortably in their wheelchairs throughout lunch and were not always given the right support at the right time to eat. Staff received training and supervision but their performances were not appraised. People remained at risk of receiving ineffective care because needs assessments continued to contradict other information within people’s care records.

There was a significant deterioration in the quality of care people received from staff when compared to our 2017 inspection. We observed people being ignored and spoken to in an impolite manner. We saw people treated in ways that were undignified and we found that people’s privacy was not always respected.

Some people’s care records continued to contain errors and duplicated information preventing them from being person centred. This included the wrong names in care records and the descriptions of the wrong person’s needs. The service acknowledged that more needed to be done to make it a dementia friendly environment. There was a complaints process in place which relatives told us they understood. Where required the service was capable of providing end of life care to people and received support from specialist to do this.

The service was inadequately managed. There was no registered manager or deputy manager in post. Management responsibility on all three floors of the nursing home was in the hands of agency staff. Some agency staff were new, some worked infrequently and some did not know people well. All were guided in the delivery of care and support by care records which in many cases contained inaccurate information. Despite receiving Warning Notices for three breaches of regulation following our 2017 inspection the provider remained in breach of two at this inspection. Further, we found the provider to be in breach of a total of five regulations at this inspection. The provider’s quality assurance processes were inadequate because they failed to identify and correct the shortfalls and poor practice we found.

The overall rating for this service is ‘Inadequate’ and the service is therefore 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.

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.

During this inspection, we identified a number of continued breaches 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 this report. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Our inspection took place on 2 August 2016 and was unannounced. At our last inspection in January 2015 the provider met the regulations we inspected.

There was a registered manager in post at the time of our inspection but they were on annual leave during our visit. 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.

Prior to our inspection of Elmwood Nursing Home we received information from the service notifying us of a serious injury that had occurred to one of the people living at the home. We are carrying out a separate investigation in to the circumstances surrounding this incident. Once we have concluded our investigation we will notify the provider of what action we intend to take, if any, as a result of our findings.

Some of the people in the home required a high level of support to meet their needs, often needing the assistance of two care workers to move them safely. Staffing levels did not take into consideration the needs of people and were not appropriate. These did not fully protect people from the risks of poor or inappropriate care. Staff were concerned that the time they spent with people was compromised and not conducive to delivering high quality care they so desired for people.

The recruitment procedures were appropriate at the time of our inspection.

The provider was aware of the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS) to help ensure people’s rights were protected. However, people’s mental capacity assessments were not completed. When a person was found to lack capacity the reasons for making decisions on people’s behalf were not clearly recorded.

People and staff were asked for their views on how to improve the service. However, there was no evidence to see how feedback was used to improve the service. Staff did not always feel listened to and supported by their manager.

The provider had systems in place to help them understand the quality of the care and support people received. However, actions and recommendations made were not always put into place.

There was an activities programme at Elmwood Nursing home and the activity coordinator tried hard to ensure people had the opportunity to be involved in meaningful pastimes to help stop them from feeling lonely or isolated, but we found people living with dementia may have benefited from more personalised engagement and stimulation.

The deputy manager and members of staff understood their roles and responsibilities to follow processes and protect people from harm. People told us they felt safe. They said staff were kind, caring and respected their privacy and dignity. People’s rooms contained personal belongings and items that were special or of personal value to them.

Staff spoke with people in a kind and sensitive way. They were helpful and polite while supporting people at mealtimes to make sure people had sufficient amounts to eat and drink. People and their relatives were positive about the food at Elmwood Nursing Home. Special dietary requirements were catered for and people’s nutritional risks were assessed and monitored.

People received their prescribed medicines at the right times, these were stored securely and administered safely by registered nurses.

People had access to healthcare services when they needed it and received ongoing healthcare support from GPs and other healthcare professionals.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to staffing, recording people’s capacity to consent to care and governance. You can see what action we told the provider to take at the back of the full version of this report

Most people we spoke with said they thought the food was good. Comments we received included “the food is very good” and “I do like the food here”. One person told us “the food’s great, really good, top rate.

Since the present providers, HC-One Limited had purchased the service a planned programme of redecoration and modernisation had been implemented. Several areas had been redecorated and refurbished. A minibus had also been given to the home.

We saw that there was a robust recruitment process in place in order to help ensure that those judged as being unsuitable to be working with vulnerable people were prevented from doing so.

There was an on-going staff training programme so that staff had the knowledge and skills to support the people using the service.

Very few of the people who use this service were able to talk with us, due to their levels of dementia. However, some of them confirmed that they were able to choose how they spent their day and which activities they joined in with. We observed that they looked quite comfortable and showed signs of positive wellbeing.

Relatives told us they were happy with the care people received and they thought people were well looked after.

All of the feedback regarding staff was very positive. People told us “they’re very good”, “very kind to me”, and “they know what to do”. Relatives confirmed that communication was good and they were always kept informed about what was going on.