CQC report explained · a residential care home
What the CQC found at Elm Bank Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2023
Rated Good overall; inspectors found people safe and well supported, but leadership and quality checks still need improvement.
This was a focused inspection on 24 and 26 April 2023. Inspectors reviewed Safe, Effective and Well-led. They spoke with people, relatives and staff, and checked care plans, medicines records, recruitment files, training records and management documents.
People told inspectors they felt safe and were treated kindly. Staff were available, trained and supported people with food, drink, healthcare and medicines. Some records and checks were not complete or detailed enough, including medicines monitoring, accident records, repositioning checks and recruitment evidence. The manager took immediate action during the inspection.
Safe and Effective were rated Good. Well-led remained Requires Improvement because quality monitoring had not always identified and fixed problems quickly enough. The overall rating is Good, but the report says the improvements in leadership need time to become established.
People felt safe
People and relatives told inspectors they felt safe. Staff understood how to recognise and report abuse.
“People were protected from the risk of abuse. People and family members told us they felt safe, and staff treated them well.” from the report
Enough trained staff
Inspectors found enough staff to meet people's needs. Staff received training, supervision and support, including induction and time shadowing experienced colleagues.
“People were supported by staff that received appropriate training and support to fulfil their roles and responsibilities.” from the report
Good health support
Staff worked with health professionals and acted when people's health changed. Care plans and risk assessments guided support with eating, drinking and swallowing.
“The service had good links with health professionals.” from the report
Kind, person-centred care
Inspectors observed staff treating people kindly and taking account of their wishes. People and relatives said communication with the home was good.
“We observed staff demonstrated kind, person centred care when interacting with people.” from the report
Quality checks were not reliable enough
needs fixingChecks on medicines, accidents and incidents, and recruitment had not always led to problems being identified and fixed promptly. The manager took action, but the improvements had not yet had time to become established.
“The systems to monitor medicines administration, accident and incidents and staff recruitment had not always resulted in areas for improvement being identified and acted upon in a timely manner.” from the report
Some safety records were incomplete
needs fixingSome accident records did not explain the action taken, and some safety and repositioning checks were not completed as often as people's assessments required. The provider acted during the inspection.
“Staff completed safety and repositioning checks, but we found some of these checks were not always completed at the frequency set out in people's individual risk assessments.” from the report
Recruitment evidence was missing
needs fixingSome staff files did not contain evidence of completed references and criminal record checks before staff started work. The manager took action to obtain the records.
“We found some staff files lacked information to evidence that full pre-employment checks had been completed.” from the report
Some medicines records needed updating
needs fixingRecords for medicines that had to be given at specific times needed closer monitoring. Some staff competency records were also incomplete.
“However, some staff medication competency records were not fully completed.” from the report
- 01What action plan is now in place for medicines, accident records and staff recruitment checks, and what evidence can you show that it is complete?
- 02How do you make sure time-specific medicines are given at the correct times and recorded properly?
- 03How do you check that repositioning and other safety checks happen at the frequency set in each person's risk assessment?
- 04Have all staff recruitment files been updated with references and DBS checks completed before staff started work?
- 05How will you show that the improvements in quality monitoring have become part of everyday practice?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected during this visit. This explanation was written from the published report of 13 June 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, February 2022
Elm Bank Care Home was inspected but not rated; inspectors found strong COVID-19 infection controls, but visiting arrangements did not always follow guidance.
This was an unannounced, targeted inspection on 13 January 2022. It focused on infection prevention and control, visiting arrangements, and whether COVID-19 staffing pressures were affecting care.
Inspectors found many good arrangements. These included visitor booking, testing, hand washing, personal protective equipment, vaccination checks, isolation plans, up-to-date policies, and regular cleaning checks.
Inspectors were not always assured that visits followed government guidance. At the time, unvaccinated visitors could not visit people in their rooms, although they could use a screened visiting area. The provider said this would change after the inspection.
The service was inspected but not rated. This was not a full assessment of the home, so the report does not give an overall quality rating or ratings for most of the five areas.
Visitor safety
The home had a booking system, rapid testing, hand washing and PPE stations for visitors and professionals.
“Safe arrangements were in place for visitors to the service including professionals and others.” from the report
Infection control planning
The home used isolation, zoning and cohorting plans to help manage the spread of infection.
“Isolation, cohorting and zoning plans were used to manage the spread of infection.” from the report
Up-to-date guidance
Policies and risk assessments about COVID-19 were up to date, and staff and visitors were kept informed about current guidance.
“Policies, procedures, risk assessments and guidance relating to COVID-19 were up to date, which supported staff to keep them and others safe.” from the report
PPE and cleanliness
PPE was readily available, staff were trained to use it, and management carried out checks to keep the home clean and tidy.
“Stocks of PPE (personal protective equipment) were readily accessible to staff and visitors, and regular checks were made to ensure they were being used.” from the report
Visiting restrictions
needs fixingAt the inspection, unvaccinated visitors were not allowed into people's rooms. Inspectors said this did not always follow government guidance, although the provider said the policy would change.
“We were not always assured the provider was facilitating visits for people living in the home in accordance with the current guidance.” from the report
- 01What is the current policy for unvaccinated named visitors entering a resident's room?
- 02When did the visiting policy change after the inspection, and how is it being checked?
- 03How are COVID-19 staff pressures currently affecting staffing and people's care?
- 04What are the home's current ratings for Effective, Caring, Responsive and Well-led?
- 05How are infection control, PPE supplies and cleaning checks monitored now?
This was an unannounced targeted inspection of infection prevention and control, visiting arrangements and COVID-19 staffing pressures; it did not assess the other key questions or provide an overall rating. This explanation was written from the published report of 9 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 Elm Bank Care Home
5 rated inspections over 8 years: the service has held its Good rating throughout.
- June 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- November 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2019Requires improvementdown from GoodSafe: GoodEffective: Requires improvementWell-led: Requires improvement
- June 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- July 2011
Registered with the Care Quality Commission on 27 July 2011.
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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