CQC report explained · a nursing home
What the CQC found at Elderflower House Nursing and Residential Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some people's risks were not fully assessed, monitored or recorded. Inspectors also found gaps in staff recruitment files, although there were enough staff and medicines were managed safely.
- Effective?
- Good
- People had thorough assessments and detailed care plans. Staff understood people's health, eating and drinking needs, and followed the Mental Capacity Act principles.
- Caring?
- Good
- Staff were kind, respectful and knew people well. People were offered choices, supported to remain independent and treated with privacy and dignity.
- Responsive?
- Good
- Care plans reflected people's individual physical, emotional and social needs. People were supported with activities, communication, relationships and complaints.
- Well-led?
- Requires improvement
- There was a management structure and an improvement plan, but further work was needed to make sure risks, staff records and management checks were consistently effective.
What inspectors found, June 2022
Elderflower House Nursing and Residential Care Home rated Requires Improvement; inspectors found kind, responsive care but gaps in risk records, staff files and oversight.
This was the home's first inspection since it registered. It was an unannounced visit on 11 May 2022. One inspector spoke with people, relatives and staff, and checked records, care, the building and infection control.
Inspectors found good care in three areas. People received kind and respectful support. Their care was personalised, meals and healthcare support were well managed, and people were helped to keep relationships and interests.
Safety and leadership required improvement. Some risks were not properly recorded or managed. Staff recruitment files were incomplete, and the new quality systems had not yet fully delivered the checks needed to show people were safe.
Kind and respectful staff
Staff spent time with people, understood what mattered to them and supported their dignity and independence.
“People were treated with kindness and respect. Staff spent time with people chatting or ding activities the person enjoyed.” from the report
Enough staff
Inspectors saw staff respond promptly and spend time with people. Staffing numbers were checked each day.
“There were enough staff to meet people's needs and keep them safe.” from the report
Good personalised care
Care plans covered people's individual preferences and needs. Staff adapted their approach when people's needs or preferences changed.
“Care plans were reflective of people's physical, emotional and social care needs.” from the report
Safe medicines and infection control
Medicines were stored and recorded correctly, and staff were trained and assessed as competent. The home was clean and infection control arrangements were considered suitable.
“People received their medicines in the right way and at the right time.” from the report
Risk records were incomplete
seriousSome risks were not fully assessed, monitored or recorded. Staff knew people’s risks, but this information was not always written clearly enough for new or agency staff.
“Risks were not always assessed managed and monitored.” from the report
Recruitment records
seriousInspectors could not be assured that staff had always been recruited safely because staff files were missing information about induction and training.
“We could not be assured that staff were recruited safely.” from the report
Management checks needed strengthening
needs fixingThe home had started new monitoring and an improvement plan, but these systems had not yet been fully put into practice or shown that risks were consistently controlled.
“However, further work was required to give assurances that people were kept safe and risks were assessed.” from the report
Upstairs bathrooms
minorTwo upstairs bathrooms needed refurbishment so they could be kept clean effectively. The work had already been planned.
“Two of the bathrooms on the upstairs corridor required refurbishment to ensure that they could effectively be kept clean.” from the report
- 01Which risk assessments were updated after the inspection, and how are they checked now?
- 02How do you make sure new and agency staff can see and follow each person's current risk information?
- 03Have all staff files been completed, including recruitment checks, induction and training records?
- 04What progress has been made with the improvement plan and management audits?
- 05Have the two upstairs bathrooms been refurbished, and if not, when will this be completed?
This was a planned, unannounced first inspection following registration and covered all five CQC questions, including infection prevention and control. This explanation was written from the published report of 18 June 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2022
Inspected but not rated; inspectors found strong COVID-19 infection control arrangements, but this was not a full service rating.
Inspectors visited the home without notice on 2 February 2022. This was a targeted inspection during the COVID-19 pandemic. They looked mainly at infection control, visiting arrangements and whether staffing pressures affected care.
Inspectors found arrangements to reduce the spread of infection. People with positive tests isolated in their rooms. Staff were divided into separate teams, and testing, protective equipment, cleaning and infection control audits were in place.
The home was meeting the COVID-19 vaccination requirement for staff and visiting professionals, unless they were exempt or there was an emergency. Inspectors were assured about the home's infection control arrangements.
The home was inspected but not rated. This means the report gives no overall quality rating and does not provide ratings for the other four questions.
Separate staff teams
Staff were divided into teams so that those supporting people with COVID-19 did not work with people who had not contracted the virus. Separate toilets and rest rooms were also used.
“A system had been implemented to divide staff into two teams. These consisted of a red team and a green team.” from the report
Staff training
Staff had training in infection control, hand washing and the safe use of protective equipment. Their infection control skills were also checked.
“Staff had been trained in infection prevention and control, food hygiene and COVID-19.” from the report
Regular testing
The home had a regular COVID-19 testing programme for staff and residents, allowing action to be taken after positive results.
“A regular programme of testing for COVID-19 was in place for staff and people who lived in the service.” from the report
Cleaning and audits
Cleaning took place throughout the day, including regular cleaning of frequently touched surfaces. Infection control audits recorded any improvements and how they were followed up.
“There was a robust infection prevention and control audit in place.” from the report
Inspectors raised no specific concerns in this report.
- 01Are the separate red and green staff teams still used, and how do you prevent staff moving between them?
- 02How are staff currently trained and assessed in infection prevention, hand washing and the use of protective equipment?
- 03What COVID-19 testing arrangements are currently in place for staff and residents?
- 04How are visits managed now, and what checks are made for visiting professionals?
- 05What arrangements are in place to manage staffing pressures if staff are absent because of infection?
This was an unannounced targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it did not rate the other questions or the service overall. This explanation was written from the published report of 11 February 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Elderflower House Nursing and Residential Care Home
8 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- June 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Elderflower House Nursing and Residential Care Home →
- February 2022Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Elderflower House Nursing and Residential Care Home →
- February 2021Inspected but not ratedSafe: Inspected but not rated
- January 2020Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2018Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2016Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- December 2015Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- December 2020
Registered with the Care Quality Commission on 23 December 2020.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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