The Royal Elms Care Home

The Royal Elms is a residential care home providing personal and nursing care to 19 people aged 65 and over at the time of the inspection. The service can support up to 26 people. The home is in one adapted building over two floors. People accessed their rooms via a stairwell or passenger lift. There are two communal lounges , a large dining room and an outside decked area.

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

The home was clean, and improvements had been made to the décor of the home and storage of personal protective equipment (PPE). Staff were aware of the latest guidance in relation to the pandemic and wore PPE when supporting people with personal care. Staff were recruited safely and staffing levels were sufficient. The registered manager had shared further information and training around safeguarding vulnerable adults and whistling blowing with staff. Staff felt confident to raise any concerns. The safety of the premises was maintained, and bathrooms had been refurbished. Medicines were given as prescribed.

Improvements has been made to the oversight and governance of the service. Audits highlighted areas for improvement. The registered manager ensured any concerning information was reported to the appropriate professionals. People felt involved in the positive changes in the home, such as the redecoration. It was evident the registered manager had been a key person in embedding and sustaining improvements across the home.

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 inadequate (published 8 December 2020) and there were multiple breaches of regulation. 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.

This service has been in Special Measures since 8 December 2020. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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

The Royal Elms is a care home providing accommodation and personal care to 20 people aged 65 and over at the time of the inspection. The service can support up to 26 people. The home is in one adapted building over two floors. People accessed their rooms via a stairwell or passenger lift. There are two communal lounges and large dining room and an outside decked area.

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

Infection control across the home was not safely managed. Personal protective equipment was incorrectly stored. Three staff members were seen to be wearing their facemask under their nose and parts of a bathroom were not clean and rust had formed on a bath. Cleaning products were accessible as the store room was not locked. The health and safety of the home was not well managed. The firefighting equipment had not been serviced in timely intervals and the gas safety check had not been completed in the time required. Risks to people did not always feed into care plans.

We have identified an incident in relation to the absence of the manager which should have been notified to CQC. We will deal with this outside of the inspection. The provider had not assessed, investigated and concluded a safeguarding allegation or supported staff to raise a safeguarding or whistle blow any concerns they had. The provider lacked oversight of the management of the service and had not ensured one staff member was safely recruited. The audit process was not robust as the issues noted during inspection had not been identified. A manager from another of the provider’s homes was overseeing the management of the home and staff found this to be supportive.

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

Rating at last inspection

The last rating for this service was good (published 15 June 2018).

Why we inspected

The inspection was prompted in part due to concerns received about the management of a safeguarding concern and because the provider had not reported the registered manager was no longer working at the home. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and we will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment, good governance and fit and proper persons employed.

Please see the action we have told the provider to take at the end of this report.

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.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe, and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions 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.

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 differing needs of people living at The Royal Elms and knew each person well.

Care plans and risk assessments were in place and reviewed at regular intervals. Both people living at the home and relatives felt they were included in the care planning.

There were activities available and we heard many people living at The Royal Elms say that they looked forward to the activities.

The service looked after people who were at the end of life. Appropriate planning was in place and the service had received the “Six Steps” award in end of life care.

A number of audits had been developed to monitor and improve the service in relation to premises safety, infection control and medicines.

People, their relatives and the staff team were very complimentary about the registered and deputy manager. The registered and deputy manager were visible within the service and had oversight of 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 approach the registered manager regarding minor issues.

There was a good range of activities provided in the home, and two staff responsible for delivering them. We saw a lively and enjoyable music and dance session. There were activities suitable for people with more advanced dementia, and the home had developed flash cards for people who could not communicate verbally.

Trips took place from time to time and there were regular pub lunches. People attended residents’ meetings.

People living in the home, their relatives and staff all had a high opinion of how the home was run and of the registered manager. Many staff were long-serving but there were some new recruits as well.

A new audit system had been introduced, but several months of medication audits had been missed. Other audits were completed but there was no analysis of accidents. We saw one error in recording DoLS applications.

The provider visited the home but there were no records of those visits. This meant there was an absence of evidence of oversight of the home. Taken with the missing audits this represented a breach of the regulation relating to good governance.

The registered manager had been involved in one disciplinary matter recently. There were regular staff meetings.

We found breaches of two regulations 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 end of the full version of the report.

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.

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.

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.