CQC report explained · a residential care home
What the CQC found at Elgin Rest 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
- The home was clean and people said they felt safe, but inspectors found unsecured wardrobes, delayed action on one medicine stock reconciliation and incomplete fire drill records. The manager took immediate action on some concerns.
- Effective?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Caring?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Responsive?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- Quality checks did not always identify or resolve problems. The manager responded to the inspection findings, but some improvement plans had no specific completion dates and there was no assessment of the need for CCTV or people's and staff's consent.
What inspectors found, April 2023
Elgin Rest Home is rated Requires Improvement; people felt safe and cared for, but safety checks, records and the building needed improvement.
Inspectors made an unannounced focused inspection over 16, 20 and 21 March 2023. They spoke with people, relatives and staff, and reviewed care plans, medicines records, incidents, recruitment records and management records.
The home was clean and free from smells. People and relatives said they felt safe and that staff were kind and caring. Staff understood people's individual risks, and medicines were generally managed safely.
Inspectors found three wardrobes were not secured to the wall, some medicine checks were not acted on promptly, and fire drill records did not show which staff had attended. The building also needed refurbishment, including damaged kitchen cupboards and redecoration in some bedrooms.
The overall rating changed from Good at the previous inspection, published in 2018, to Requires Improvement. Safe and Well-led were rated Requires Improvement. The other areas were not inspected during this visit and carried forward their previous ratings.
People felt safe
People and relatives told inspectors they felt safe and were happy with the support provided.
“People and relatives told us they were safe.” from the report
Kind and caring staff
Inspectors found staff interacted well with people and responded in a timely way. People and relatives spoke positively about the care.
“People living at Elgin Rest Home were happy with the support they received.” from the report
Staff understood individual risks
Staff knew people well and understood the risks linked to their health and support needs.
“Staff knew people very well and understood risks associated with individuals.” from the report
Manager acted during inspection
The manager responded promptly to the concerns found and secured the wardrobes by the second day of the inspection.
“The registered manager was responsive, and all concerns found were actioned during the inspection.” from the report
Mental capacity practice
Inspectors found the home was working within the principles of the Mental Capacity Act and that required legal authorisations were in place.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place” from the report
Unsecured wardrobes
seriousThree wardrobes were not secured to the wall, creating a possible injury risk. They were secured by the second day of the inspection.
“Three wardrobes were not secured to the wall which could expose people to risk of injury.” from the report
Weak quality checks
needs fixingAudits did not always identify problems or ensure that known issues were resolved. This included maintenance, medicines records and fire drill records.
“Systems in place to monitor the service were not always effective.” from the report
Building needs refurbishment
needs fixingThe kitchen cupboards were damaged and some bedrooms needed redecoration. The planned kitchen refurbishment was not due in the short term.
“People lived in an environment that needed upgrading and refurbishment.” from the report
Fire drill records
needs fixingThe home said fire drills took place, but records did not show which staff had attended. The manager planned to introduce a staff fire drill register.
“There were no records to indicate which staff had attended.” from the report
CCTV assessment
needs fixingCCTV was used in communal areas, but inspectors found no assessment explaining why it was needed or whether people and staff had consented.
“There was no assessment found about why the CCTV was needed or if people and staff had consented to its use.” from the report
- 01Which maintenance and refurbishment problems have been completed since the inspection, especially the kitchen cupboards and bedroom decoration?
- 02How do you now check that medicine stock discrepancies are acted on promptly?
- 03Do fire drill records now show which staff attended, and how often are drills carried out?
- 04What assessment has been completed about the need for CCTV in communal areas, including consent?
- 05How do your current audits make sure identified problems are completed by a clear date?
This was an unannounced focused inspection of Safe and Well-led only, following a safeguarding concern; the other ratings carried over from the previous inspection. This explanation was written from the published report of 28 April 2023 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, March 2018
Rated Good in all five areas after inspectors found the required improvements had been made.
Two inspectors visited the home without notice on 6 February 2018. They spoke with eight people, three relatives, the registered manager and care staff. They reviewed care records, staff files, medicines, complaints, audits and policies.
The inspectors found people were safe and received enough staff support. Medicines were managed safely, staff had suitable training, and checks were made when recruiting staff. People received enough food and drink and were supported to access healthcare.
The report describes staff as kind, respectful and knowledgeable about people's routines and preferences. Care plans were personalised, activities were available, complaints were investigated, and people were supported at the end of life.
The home had previously been rated Requires Improvement overall. Safe remained Requires Improvement and Well-led was Inadequate at a later focused inspection. At this inspection, the provider had taken the required action and all five areas were rated Good.
Safe medicines practice
Only trained and competent staff gave medicines. Medicines were stored safely and regular audits were completed.
“Medicines were managed and administered safely.” from the report
Kind and respectful staff
Staff knew people's histories, preferences and routines. Inspectors saw positive relationships and a relaxed atmosphere.
“Staff treated people with dignity and respect.” from the report
Individual care and activities
Care plans were tailored to each person and reviewed regularly. People could take part in varied activities that interested them.
“We saw that care plans were very detailed and tailored to each individuals care and support needs.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you check that medicines are given on time and that any errors or concerns are acted on?
- 02What training and supervision do staff receive for the specific needs of the person we are considering?
- 03How often will our relative's care plan and risk assessments be reviewed and updated?
- 04What decoration, flooring or carpet work remains, and how will it affect residents?
- 05How will you use our relative's views and feedback to improve their care?
This was an unannounced inspection of the overall service and all five CQC questions, following earlier concerns about Safe and Well-led. This explanation was written from the published report of 15 March 2018 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 Elgin Rest Home
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- April 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- July 2017Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Inadequate
- April 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2014
Registered with the Care Quality Commission on 1 July 2014.
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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