CQC report explained · a residential care home
What the CQC found at Elm Lodge Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- Inspectors found that risks, safeguarding, staffing and medicines were managed safely. They did note incorrect face-mask use by two staff and some overstocked medicines.
- Effective?
- Requires improvement
- This question was not inspected during this visit. Its previous rating was carried forward to the overall rating.
- Caring?
- Requires improvement
- This question was not inspected during this visit. Its previous rating was carried forward to the overall rating.
- Responsive?
- Requires improvement
- This question was not inspected during this visit. Its previous rating was carried forward to the overall rating.
- Well-led?
- Good
- Inspectors found effective management checks, an open atmosphere and good involvement of people, relatives and staff. A few equipment replacements had not been completed promptly.
What inspectors found, October 2022
Elm Lodge Care Home is rated Requires Improvement overall; inspectors rated Safe and Well-led Good, but some safety and maintenance issues remained.
This was an unannounced, focused inspection on 8 August 2022. Inspectors spoke with people, relatives and staff, observed care, and checked care plans, medicines records, staffing records and management checks.
The home was rated Good for Safe and Well-led. Inspectors found people were protected from abuse, risks were managed, medicines were given safely, staffing levels were suitable and managers had improved the way the home was monitored.
Some issues still needed attention. These included incorrect use of face masks by two staff, a few items needing replacement, incomplete information in one recruitment record, overstocked medicines and food portions that were too large for some people.
The overall rating remains Requires Improvement because this inspection only covered Safe and Well-led. The ratings for Effective, Caring and Responsive were carried forward from the previous inspection.
People were protected
The home had arrangements to protect people from abuse and avoidable harm. Staff understood how to recognise and report concerns.
“People were protected from the risk of harm or abuse within the service.” from the report
Medicines were managed safely
Staff responsible for medicines were trained and checked. Inspectors saw medicines being stored, given and recorded safely.
“People's medicines were safely managed, and people received their medicines when they should.” from the report
Staffing was suitable
Records showed required pre-employment checks had usually been completed, and inspectors found enough staff were available to provide care.
“There were enough staff to provide people's care.” from the report
Management had improved
The provider had strengthened its monitoring, care planning and risk management since the previous inspection.
“This demonstrated embedded and sustained service improvement from our last inspection, such as improved governance, care planning and risk management measures for people's care.” from the report
People were involved
Inspectors found an open and friendly atmosphere. People, relatives and staff were consulted about care and improvements.
“There was an open, friendly atmosphere at the service where overall people, relatives and staff felt consulted and involved.” from the report
Face masks were not always worn correctly
needs fixingInspectors saw two staff members wearing face masks incorrectly. Relatives had also noticed this at times.
“However, during this inspection, we saw two staff did not always wear face masks correctly, thereby negating safe use.” from the report
Some equipment replacements were delayed
needs fixingA few items, including a waste bin, linen trolley and light bulb, had not always been replaced promptly. The provider later sent evidence that this had been addressed.
“However, we found a few areas of equipment renewal that were mostly identified by the provider as needed, but not always completed in timely manner.” from the report
One recruitment record was incomplete
minorOne staff recruitment file did not include the full dates of previous employment and education. The manager said this was corrected after the inspection.
“However, in one staff member's recruitment records we reviewed, the full dates of their previous employment and education were not provided.” from the report
Some medicines were overstocked
minorInspectors found more of some medicines in the home than needed. The provider was advised to reduce unnecessary waste.
“We found overstocking of some people's medicines within the service.” from the report
Food portions were too large for some people
minorFeedback raised concerns about meal presentation, and inspectors saw portions that were very large and unsuitable for two people observed.
“Two felt meal presentation could be improved, which we also saw in relation to food portion sizes, which were very large and over-facing for two people we observed.” from the report
- 01What checks are now in place to make sure all staff wear face masks correctly when required?
- 02Have the waste bin, linen trolley and light bulbs been replaced, and how do you make sure future repairs are completed promptly?
- 03How do you prevent medicines from being overstocked and reduce unnecessary medicines waste?
- 04How are food portions tailored to each person's needs and preferences?
- 05What are the current ratings and findings for Effective, Caring and Responsive, which were not inspected during this visit?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 11 October 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 infection control and enough staff to meet people's needs on the day.
This was an announced, targeted inspection on 21 January 2022. It focused on infection prevention and control during the COVID-19 pandemic, and on whether staffing pressures were affecting care.
Inspectors found clear visiting rules, regular cleaning, suitable use of protective equipment, testing arrangements and an up-to-date infection control policy. They were assured that the home was managing visits, admissions, outbreaks and social distancing safely.
Inspectors observed enough staff on shift to meet people's needs safely. The home was inspected but not rated, so this report does not provide a Good, Requires improvement or other quality rating.
Visiting arrangements
The home had clear visiting procedures. Visitors were given instructions about protective equipment, COVID-19 testing and health screening.
“The service had clear visiting protocols in place with robust infection, control and prevention procedures that all visitors were required to follow.” from the report
Cleaning
The home was cleaned regularly throughout the day, including areas touched frequently.
“The service was regularly cleaned throughout the day. There was cleaning schedules which staff followed, these included regular cleaning of high touch areas.” from the report
Protective equipment
Staff had infection control training and inspectors saw them wearing the correct protective equipment during the visit.
“We observed staff to be wearing the correct PPE throughout our inspection.” from the report
Staffing on the day
The provider described measures to manage COVID-19-related staffing pressures. Inspectors saw enough staff on shift to meet people's needs safely.
“We observed there were enough staff on shift to safely meet people's needs.” from the report
Inspectors raised no specific concerns in this report.
- 01Are the visiting rules, health screening and COVID-19 testing arrangements still the same as those described in the report?
- 02How do you make sure staff continue to use protective equipment correctly?
- 03How do you manage staffing pressures when staff are absent because of COVID-19?
- 04How often are high-touch areas cleaned, and how do you check that cleaning schedules are followed?
- 05How do you keep the infection prevention and control policy up to date?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; it was inspected but not rated and did not provide ratings for the other areas of care. This explanation was written from the published report of 4 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 Lodge Care Home
6 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- October 2022Requires improvementcurrent ratingSafe: GoodEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Good
- February 2022Inspected but not ratedSafe: Inspected but not rated
- September 2019Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- February 2019Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2018Requires improvementstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- December 2012
Registered with the Care Quality Commission on 6 December 2012.
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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