CQC report explained · a nursing home
What the CQC found at Elizabeth Fleming Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were considered safe, there were enough staff, recruitment was safe and medicines were managed safely. Some risk assessments were too general, but the manager took immediate action to review them.
- Effective?
- Good
- Staff had the training and support they needed. People were supported with food, drink and healthcare, and the home followed the Mental Capacity Act requirements.
- Caring?
- Good
- People said staff were kind and treated them with respect. Staff supported people to make choices and remain as independent as possible.
- Responsive?
- Good
- Care plans were personalised and updated when needs changed. Activities had reduced, but the home was taking steps to improve them.
- Well-led?
- Good
- Staff found the manager approachable and quality checks were carried out. Inspectors recommended more regular formal involvement of people and relatives.
What inspectors found, November 2022
Elizabeth Fleming Care Home was rated Good; inspectors found kind, safe care, but some risk assessments, activities and family communication needed improvement.
This was the first inspection since the home registered. It was unannounced and took place on 13 July 2022 and 19 August 2022. One inspector spoke with people, relatives and staff, and reviewed care records and other documents.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines management, suitable staff training, personalised care plans and kind treatment.
Some risk assessments were too general and did not explain clearly how to keep people safe. The manager acted immediately to improve them. Relatives also wanted better communication, more formal involvement, more activities and further improvements to the home and garden.
Enough staff
Inspectors found staffing levels were sufficient to meet people's needs, and people said staff responded quickly when help was needed.
“Sufficient staff were available to meet people's needs.” from the report
Personalised care
Care plans described people's needs, preferences and wishes. They were reviewed and updated when needs changed.
“Care plans were reviewed frequently and updated when people's needs changed.” from the report
Safe medicines
Records showed people received their medicines on time. Staff were trained and their competence was checked.
“Medicines administration records confirmed people received their medicines on time.” from the report
Kind and respectful care
People described staff as kind and said they had positive relationships with them. Staff supported people's dignity and independence.
“People had developed positive relationships with care staff.” from the report
Risk assessments
needs fixingSome risk assessments lacked specific information about how to keep people safe. The manager acted immediately to review and improve them.
“Some risk assessments were often general and lacked specific information about how to keep people safe.” from the report
Family involvement
needs fixingRelatives' meetings were infrequent and there had been no recent formal consultation with people and relatives. Inspectors recommended a more regular approach to gathering feedback.
“Improvements were needed to ensure people and residents were fully engaged.” from the report
Activities
needs fixingThe range of activities had reduced from the previous programme. The home had recruited new activities staff and was trying to improve this.
“The provision and range of activities within the home had decreased from what had previously been a fuller activity programme.” from the report
Environment and gardens
minorRelatives said the home looked tired and that the garden spaces had been neglected. Improvements had started, but further work was still needed.
“Relatives had been integral in improving the garden spaces for people living at the home to enjoy, as they said these had been neglected.” from the report
- 01What changes have been made to the risk assessments since the inspection, and how are they checked now?
- 02How often are relatives' meetings and formal consultations held now?
- 03What activities are currently available, and how often can residents take part?
- 04Which environmental and garden improvements are still outstanding, and when will they be completed?
This was a planned inspection covering all five key questions, including infection prevention and control under Safe; it was the home's first inspection. This explanation was written from the published report of 18 November 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, December 2020
Inspected but not rated; inspectors were assured that infection prevention and control arrangements were safe.
The CQC carried out a targeted inspection on 30 November 2020, with very short notice. It looked only at infection prevention and control because of coronavirus outbreaks in care homes.
Inspectors found systems for safe visiting, social distancing, personal protective equipment, safe admissions and regular Covid-19 testing for people and staff. They were also assured that the home had suitable hygiene, infection control and outbreak arrangements.
The home was inspected but not rated. This means the inspection did not give an overall quality rating or a rated judgement for the other areas of care.
Safe visiting
The home screened visitors before they entered to reduce infection risk.
“Systems were in place to allow safe visiting, including screening visitors to reduce any potential infection risk, before they entered the building.” from the report
Social distancing
The home encouraged social distancing and changed communal areas to support it.
“Social distancing was encouraged, and changes had been made to communal areas to promote this.” from the report
PPE and training
Staff used personal protective equipment, and training had been provided on infection control and its correct use.
“Staff wore personal protective equipment (PPE). Training in infection prevention and control measures and the appropriate use of PPE had taken place.” from the report
Testing and admissions
The home had arrangements for admitting people safely and regularly testing people and staff for Covid-19.
“A regular programme of Covid-19 testing was in place for people and the staff team.” from the report
Outbreak planning
Inspectors were assured that the home had arrangements to prevent or manage infection outbreaks and that its infection control policy was up to date.
“We were assured that the provider's infection prevention and control policy was up to date.” from the report
Inspectors raised no specific concerns in this report.
- 01How have your visiting arrangements changed since the inspection?
- 02How often are people using the service and staff tested for Covid-19 now?
- 03What happens if there is an infection outbreak in the home?
- 04How do you make sure staff use personal protective equipment safely?
- 05Can you show us your current infection prevention and control policy?
This was a targeted inspection of infection prevention and control, including the Safe question; it did not assess the other four questions or provide an overall rating. This explanation was written from the published report of 10 December 2020 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 Elizabeth Fleming Care Home
3 rated inspections over 7 years: the service has held its Good rating throughout.
- November 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2020Inspected but not ratedSafe: Inspected but not rated
- September 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- April 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2020
Registered with the Care Quality Commission on 1 June 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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46 live-in carers within about an hour of Sunderland
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £950 to £1,210 a week. 42 can care for a couple. 10 years' experience on average.
“Petty introduced herself to Mum every time she was caring for her and responded very quickly to Mum if she was distressed in the night.”
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