CQC report explained · a nursing home
What the CQC found at Elm House Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Staffing was sufficient and people said they felt safe, but some environmental checks and medicines records were not always up to date or accurate.
- Effective?
- Good
- This question was not inspected during this visit. The rating from the previous inspection was used when calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this visit. The rating from the previous inspection was used when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this visit. The rating from the previous inspection was used when calculating the overall rating.
- Well-led?
- Requires improvement
- The management team supported a positive and person-centred culture, but governance systems were not always reliable. Checks, medicines records, accident analysis and some care records needed improvement.
What inspectors found, January 2024
Rated Good overall, but well-led Requires Improvement because some safety, medicines and care records were not reliable.
Inspectors visited on 4 and 5 December 2023. The first day was unannounced and the second was announced. They observed care, checked the home, spoke with people, relatives, staff and managers, and reviewed care plans, medicines records and quality checks.
The home was rated Good for safety. People were protected from abuse, staffing levels were sufficient, recruitment was safe, and people said they felt safe. The home was clean, and people could receive visitors without restrictions.
The well-led rating fell from Good to Requires Improvement. Some fire safety and window restrictor checks were overdue. Medicines records, accident analysis and some care records were not always accurate or detailed enough. The home had started to address these issues, and the overdue safety checks had been completed by the end of the inspection process.
Enough staff
Inspectors found there were enough suitable staff, and people’s needs were met promptly by staff who knew them well.
“The provider ensured there were sufficient numbers of suitable staff.” from the report
People felt safe
People and relatives told inspectors they felt safe at the home. Safeguarding systems were in place to respond to concerns.
“People and their relatives told us they felt safe living at the home.” from the report
Clean environment
The home was observed to be clean and well maintained, with infection prevention arrangements in place.
“We observed the home to be clean and well maintained.” from the report
Positive culture
People, relatives and staff gave positive feedback about the managers and the supportive atmosphere.
“The manager helped shape a positive, person-centred, open and inclusive culture at the service.” from the report
Overdue safety checks
needs fixingSome fire safety checks were overdue, and window restrictor checks had not been completed for two months. The home responded during the inspection, and all actions had been completed by the end of the inspection process.
“Some fire safety checks were overdue and window restrictor checks had not been completed for the last 2 months.” from the report
Medicines records
seriousInspectors were not assured that medicines records were always accurate. Some stock balances did not match the medication administration records, and an administration error in recording medicines was found.
“Medicines records were not always maintained in an accurate and reliable way.” from the report
Care plan detail
needs fixingSome care plans did not give staff enough specific guidance. For example, an instruction to reposition someone regularly did not say how often checks should be made.
“Further information was needed to detail how often these checks should be made.” from the report
Quality monitoring
needs fixingThe home needed stronger systems for analysing accidents and identifying patterns. Daily records did not always show the support provided, including some fluid output records.
“Although any accident and incidents were recognised and recorded, systems to analyse patters and trends required further strengthening, to help further improve safety and reduce any related risks.” from the report
- 01How are you checking that medicines stock balances match the medication administration records?
- 02How often are fire safety and window restrictor checks now completed and recorded?
- 03What changes have you made to make care plans give staff clear, specific instructions?
- 04How do you analyse accidents and incidents to identify patterns and prevent them happening again?
- 05What formal feedback methods will you introduce for people and relatives?
This inspection looked only at Safe and Well-led because the previous rating was considered old; the other three question ratings were carried forward from the last inspection. This explanation was written from the published report of 9 January 2024 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
Elm House Nursing Home had a targeted inspection and was not rated; inspectors were assured about infection prevention and control.
Inspectors visited on 13 November 2020. The visit was announced and focused only on infection prevention and control during the coronavirus pandemic.
They were assured that the home managed visitors, admissions, personal protective equipment, testing, shielding, social distancing, hygiene and possible outbreaks appropriately. Staff were seen wearing the correct protective equipment.
The home was inspected but not rated. This was not a full inspection of the quality of care, and the report does not give ratings for the other areas.
Visitor safety
Visitors had health screening, temperature checks, face masks, protective equipment and handwashing or sanitiser facilities. A screened visiting area had also been created.
“All visitors were asked to complete a health screening form, have their temperature checked and were provided with face masks to wear throughout their visit.” from the report
Use of protective equipment
Inspectors saw staff using the correct protective equipment throughout the visit. People also said staff wore it during personal care.
“We observed staff to be wearing the correct personal protective equipment (PPE) throughout the inspection.” from the report
Testing and staff training
People and staff were taking part in regular COVID-19 testing, including bank staff. Staff had training for their roles and for managing COVID-19.
“People and staff were taking part in regular COVID19 testing. Bank staff were included in the testing process.” from the report
Visiting arrangements
Individual risk assessments considered each person's visiting arrangements, including the therapeutic and mental health benefits of contact with relatives.
“People had individual risk assessments in place that reflected their specific relative visiting arrangements.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you carrying out regular COVID-19 testing for people, permanent staff and bank staff now?
- 02How do you manage visits, including health screening, protective equipment and the screened visiting area?
- 03What arrangements are in place for someone who has a positive COVID-19 diagnosis?
- 04How do you make sure staff remain trained and confident in infection prevention and control?
- 05When was the infection prevention and control policy last reviewed?
This was a targeted inspection of infection prevention and control because the home had been identified as a designated care setting; it was not a full inspection and the service was not rated. This explanation was written from the published report of 2 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 Elm House Nursing Home
5 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- January 2024Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- February 2018Goodstayed GoodSafe: GoodWell-led: Good
- July 2017Goodup from Requires improvementEffective: GoodWell-led: Good
- February 2017Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- April 2011
Registered with the Care Quality Commission on 1 April 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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Most charge £980 to £1,270 a week. 34 can care for a couple. 11 years' experience on average.
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