The Royal Elms Care Home

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked at 7 quality statements in this domain. People and their relatives felt safe living at The Royal Elms and staff took action to manage risks. They said they had been involved in agreeing people’s care and support needs when they moved in and were kept informed of any changes in their needs or wellbeing. This involvement was not recorded. Staff knew people’s needs and how to support them, however, care plans did not always contain sufficient detail to guide staff in managing risks, for example if a person became agitated. The registered manager addressed these issues during the assessment. Relatives said there were enough staff on duty. Staff feedback was more mixed. We observed staff were stretched, and there were periods of time when there was no staff available in the communal areas of the home. People received their medicines as prescribed. Additional details on how people communicated they needed an as required medicines was needed. The site of where medicated patches were applied needed to be recorded to avoid using the same site too often. Equipment was serviced and maintained appropriately. The home was clean and personal protective equipment was available. People’s capacity to make decisions was assessed and best interest decisions recorded. Records did not show who had been involved in making the best interest decision. Staff recruitment procedures ensured checks were made prior to the staff member starting work. However, references weren’t always verified and gaps in employment history were not always explained. Staff received the training for their role, and all had completed or been enrolled on a relevant health and social care diploma. Some staff needed their training refreshed. We discussed if staff required further training for managing people’s behaviours and dysphagia. There were a small number of people living at the home where this specific training could support the staff team.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Relatives said people were safe living at Royal Elms. They said there was good communication with the home. One relative said, “They let me know if there are any issues or changes.” Relatives said actions were taken following an accident to try to prevent a reoccurrence.

Staff explained how they would report any incidents or accidents. They said these were discussed in handovers. The registered manager said they reviewed the incident forms and the ABC forms. They were then discussed with the staff team.

Whilst some incident and accident forms were being completed we found a choking incident had not been recorded as an incident. The home used Antecedent, Behaviour, Consequence (ABC) forms to record any behavioural concerns. The registered manager reviewed these and discussed them with the staff team. However, no guidance had been provided for staff in how to manage these behaviours. Incident reports would be completed if there was any physical aggression during an incident.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and relatives told us they felt safe while living at The Royal Elms Care Home and could speak to the staff if they had any concerns.

Staff knew how to report any safeguarding concerns and what they needed to report. They said the registered manager would listen and respond to their concerns. Staff explained how they sought people’s consent before providing any support through explaining what they were doing.

We observed staff giving people every day choices and seeking their consent. However, we also saw staff not always engaging with people or standing over them when supporting them with their meal. Safe moving and handling techniques were used during our assessment.

Capacity assessments and best interest decisions were completed; however, there was no indication of who else was involved in the decisions, for example people’s relatives. The registered manager said they would record all people involved in best interest decisions going forward. Where people lacked capacity to make a decision, an application was made to deprive the person of their liberty. We found some people had been subjected to acts of agitation from other people living at the home and we were not assured guidance had been provided for staff promptly to reduce any further occurrences. We were told the person had settled since this had occurred and incidents had reduced.

Relatives said they were involved in agreeing people’s support needs when they first moved in and were kept up to date with any changes in their relative’s needs. A relative told us the home had worked hard trying different ways to manage the risk of their relative having a fall. Another relative said they had observed staff supporting a person who had become agitated patiently and they had dealt with the situation well. Relatives said the staff team knew people, and their needs. A relative said, “They (the care staff) just know exactly who [Name] is.”

Staff were aware of potential risks people may face and how to support them. They said they discussed people’s support needs, including new people moving into the home, during handovers and were also able to read people’s care plans. Staff said if people became agitated they would try to engage with them to support them to calm, or on other occasions people needed some space to be able to settle. We were told relatives were informed when people’s needs changed.

Staff were not always available to support people in the communal areas of the home. We observed one person becoming distressed and staff tried to manage this in a positive way by talking to the person in a calm manner.

Risk assessments were completed and regularly reviewed for a range of areas, including weight loss, moving and handling and skin integrity. However, the risk assessments did not always identify how the person should be effectively supported. For example, we found one person who could become agitated and aggressive did not have an appropriate risk assessment in place. There was evidence other people and staff had been placed at risk, and further strategies to ensure everyone’s safety had not been explored and documented. We found where people were at risk of choking, care records were not always reflective of the risk. One person had had a choking incident. There was no choking risk assessment in place and although the provider had taken action and changed the individual’s diet to a soft diet, the care records had not been updated to evidence this. The same person’s mobility had changed, and they now used a wheelchair, and the care records recorded the person was independent using a walking stick. We saw one person had fallen on the stairs and sustained an injury. Even though the person had now been moved to the ground floor, robust risk assessments were not in place to manage the risk of them accessing the stairs when unsupervised. Therefore, actions had been taken to manage risks, but the records did not always support this. There was no evidence people, and their representatives were involved in care planning or agreeing to the care interventions being provided, although relatives were informed if people’s needs changed.

People told us their environment was nice and safe. The home was being refurbished and painted.

Staff said a maintenance book was used for any repairs needed and these were completed promptly.

The home had been refurbished and redecorated. The environment was generally tidy and well maintained. During the visit, we found the room opposite the deputy’s office was not locked and contained prescribed creams. This put people at risk of unauthorised access. On reviewing bedrooms, we found some wardrobes were not fixed to the wall. We were told the risks of a person pulling at a wardrobe were assessed and where needed wardrobes were then attached to the wall to prevent injury. There were two sets of stair wells in the home, one had gates at the top and bottom to prevent unauthorised use but the other only had a gate at the top of the stairs which meant people could still climb the stairs and be at risk of falls. We were told the gate at the bottom had been removed as one resident may become agitated if they were unable to unbolt it. Gates on the stairs were not always secured. A risk assessment for the stairs was completed during our assessment.

A range of weekly and monthly checks were in place including for the fire alarm, fire doors, water temperatures, wheelchairs, and window locks. Equipment was serviced in line with legal requirements, for example lifts, hoists, gas safety and electrical system. A programme of redecoration and refurbishment was in place.

Relatives said the staff were kind, knew people’s needs well and that they had a good relationship with them. A relative said, “We always see the same staff; they are all kind and friendly” and another told us, “They are so customer focused; focused on the service for that person.”

We received mixed feedback about staffing, with some staff saying there were enough and others thinking they needed more. There were 5 people who needed 2 staff to support them, which meant during these times there was only 1 other member of care staff to support other people. The registered manager said they would be present in the dining room in the morning to support people with breakfast while the care staff supported people in getting up. Staff felt they had the training for their role, with many courses being workbooks they had to complete. Face to face courses for moving and handling were also provided. Staff said they felt supported and had supervisions every 6 months. They also said staff meetings were held when needed. They were able to raise any issues they wanted to within these meetings. They said they could speak with the registered manager at any time. There was always an on-call manager available if they needed advice.

Our observations were that staff were stretched. There were periods of time where there was no staff present in communal areas to check on people’s wellbeing.

Staff recruitment processes could be improved. We found one newly recruited staff member had references predating the employees start date as the company had closed. For another newly recruited staff member, previous employers had not been considered as a referee. We advised additional character references could be obtained in these circumstances. Gaps in their employment history had not always been explored. Staff were not receiving regular supervision with only one supervision being completed for all staff members so far in 2024. Staff were provided with an induction when they commenced employment and training pertinent to their job role. All care staff had completed or were enrolled on an NVQ level 2 or 3 diploma in health and social care course. We discussed the frequency of refresher training with the registered manager as some staff had completed courses 3 years ago and not had a refresher. We also discussed whether staff needed more training for managing people’s behaviours and dysphagia. At the time of our assessment there were few people who became agitated or were at risk of choking living at the home. Staff were assessed on their competency to move and handle people safely as part of the training course. A deputy manager observed people’s moving and handling practice in a spot check based on their own experience.

People and relatives said the home was clean.

Staff said there was a plentiful supply of personal protective equipment (PPE). Domestic staff were on duty every day and said they had enough cleaning products.

The home was clean and had undergone a programme of redecoration. There were some rooms with high ceilings which required further cleaning as cobwebs had gathered in the corners of the room. Housekeeping staff were on the rota daily and we observed them operating throughout the site visit. Staff had access to personal protective equipment (PPE) as needed.

Health and safety and infection control checklists were used to ensure equipment was regularly cleaned and operating correctly, for example wheelchairs and hoists.

People and relatives said they received their prescribed medicines as planned. A relative told us the medicines had been changed to a liquid format when their relative had difficulty swallowing the tablets.

Staff who administered medicines said they had received training and were observed prior to administering medicines themselves.

People received their medicines as prescribed. As required (PRN) protocols were not always in place. Those that were did not include details of how people would communicate they needed the PRN to be administered. Staff did not record when they added thickener to drinks to reduce the risk of choking. There was no record of where patches had been applied to ensure the same site was re-used too frequently. There was no information recorded in the care plan regarding the application of the patch. Action was taken on all these issues during our assessment. Tablet counts did not always correspond to the PRN record sheet. Where discrepancies were found during stock checks there was no evidence on the record sheet of trying to establish why the count was different. This was captured on the medicines audits for the medicines checked in each audit. Medicines competencies were completed, for including night staff. We observed medicines being administered safely. The member of staff explained what they were doing, asked if people needed a pain killer where this was prescribed and was patient whilst doing this.