CQC report explained · a nursing home
What the CQC found at Elm Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2023
Rated Good overall; inspectors found kind, personalised care, but Safe Requires Improvement because medicines practices and some safety hazards needed improvement.
This was an unannounced focused inspection on 31 January 2023. Inspectors checked whether the home had followed its improvement plan after the previous inspection. They spoke with people, relatives and staff, observed care, and checked care, medicines, staffing and management records.
The home was rated Good overall. People said they felt safe, well cared for and listened to. Inspectors found personalised care, suitable staffing, good activities, welcoming visits and effective systems for complaints, incidents and quality checks.
Safe was rated Requires Improvement. Inspectors found problems with some medicines records and procedures, as well as a small number of environmental hazards. The home took action after these issues were raised, and inspectors found it was no longer breaching Regulations 12 and 17.
Kind and personalised care
People said staff were kind and knew them well. Inspectors found that care was personalised and staff responded to people's preferences and needs.
“People told us they were well cared for and supported. They liked the staff and felt their needs were met.” from the report
Good communication and activities
The home assessed communication needs and offered information in different formats or languages when requested. People could take part in activities and leisure pursuits that suited them.
“People's communication needs were assessed, monitored and met.” from the report
Supportive leadership
Inspectors found an open and positive culture. Staff said they felt supported, and managers used audits, feedback and incident reviews to identify improvements.
“There were effective systems for monitoring and improving quality at the service.” from the report
Good staffing and safeguarding
Inspectors found enough suitable staff, with recruitment checks, training and competency assessments. People and relatives said they felt safe.
“There were enough suitable staff to keep people safe and meet their needs.” from the report
Medicines records and procedures
seriousInspectors found that some topical medicines and medicated patches were not fully recorded. They also found an incorrectly stored medicine, a medicine not given according to instructions and gaps in fridge temperature monitoring.
“People received their medicines as prescribed. However, we identified a number of practices where improvements were needed to make sure medicines were always managed safely.” from the report
Environmental hazards
needs fixingInspectors identified a small number of potential safety hazards in the environment. Staff took action during the inspection and put systems in place to reduce the chance of them happening again.
“During our inspection, we identified some potential environmental hazards.” from the report
Some care records needed clearer detail
needs fixingA small number of care records did not clearly describe people's needs. Staff corrected the examples discussed during the inspection.
“We found some care records did not always clearly reflect people's needs.” from the report
- 01What exact changes have been made to recording topical medicines and rotating medicated patches?
- 02How do you now check that medicines are stored correctly and that fridge temperatures are monitored as required?
- 03What environmental hazards were found, and how do you check that they have not returned?
- 04How are care records checked to make sure they clearly reflect each person's current needs?
- 05How will you monitor the improvements promised after this inspection?
This was a focused inspection of Safe, Responsive and Well-led only; Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 24 February 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, January 2022
Elm Lodge was rated Requires Improvement; inspectors found kind and effective care, but safety risks and weak quality checks needed fixing.
This was an unannounced inspection on 8 and 9 December 2021. Inspectors spoke with people living there, staff and visiting professionals. They observed care and checked care, medicines, recruitment, infection control and management records.
People were generally happy with their care. Staff knew people's needs, supported food and drinks, offered activities and worked with health professionals. Medicines were given as prescribed, and people were treated with kindness, dignity and respect.
The main problems were with safety monitoring and record keeping. Inspectors found an unlocked cleaners' cupboard, dirty areas in a kitchenette and incomplete records about repositioning support. These issues led to breaches of Regulation 12 and Regulation 17. The overall rating and the Safe and Well-led ratings were Requires Improvement, while Effective, Caring and Responsive were Good.
Kind and respectful staff
People and professionals generally described staff as kind and respectful. Inspectors observed caring treatment across the home.
“We also observed staff treating people with respect and in a caring manner across all the units during our visit.” from the report
Personalised support
Care plans included people's likes, dislikes, routines and communication needs. Staff showed good knowledge of the people they supported.
“Staff supported people in a planned way that recognised and met their individual care needs.” from the report
Health and nutrition support
Staff monitored nutrition when needed and worked with a range of health professionals to support people's care.
“The service worked collaboratively with other agencies to understand and meet people's needs.” from the report
Activities and visiting
People were offered activities based on their preferences. The home also supported visits and contact with families in line with guidance at the time.
“People were offered a range of activities, curated by a dedicated activities coordinator.” from the report
Medicines systems
People received medicines as prescribed. Staff were trained and managers carried out regular medicines checks.
“People were supported to take the medicines as prescribed.” from the report
Safety risks were not always controlled
seriousA cleaners' cupboard was left open and contained cleaning products, including one without its tamper-proof cap. A kitchenette also had dirty fridges and flooring.
“We found a storage cupboard used by cleaners on one unit was open when it was meant to be kept locked to keep people safe.” from the report
Care records were incomplete
seriousRecords did not always show that a person had received required two-hourly repositioning support, or that the support had been refused. This reduced assurance that people were protected from harm.
“daily care records over the four weeks prior to our visit did not always note that this support was provided as required, or was refused by the person.” from the report
Quality checks did not act quickly enough
needs fixingThe provider carried out audits, but these had not consistently found and dealt with safety and record-keeping problems in good time.
“This system had not always been effective as it had not enabled the provider to take timely action to address some of the areas for improvement we had identified.” from the report
Some preferences were not followed
needs fixingOne person's care plan requested female staff for personal care, but records showed male staff had been involved. Managers were asked to review the arrangements.
“We raised this so they could review the staffing arrangements to ensure these always recognised people's preferences.” from the report
Some people were unsure how to complain
minorAlthough complaints information was displayed and systems were in place, most people spoken with were not clear about how to raise a complaint.
“Most people we spoke with were not always clear if they knew how to raise a complaint” from the report
- 01What has been done to keep cleaners' cupboards locked and all cleaning products safely secured?
- 02How do managers now check that cleaning of kitchenettes, fridges and floors is completed and recorded?
- 03How are you making sure repositioning support is provided as planned and accurately recorded, including when someone refuses it?
- 04How will the home make sure staff follow each person's preferences about who provides personal care?
- 05What will you do to ensure people and relatives understand how to make a complaint?
This was the first comprehensive inspection under the current provider and covered all five key questions, including infection prevention and control; the previous rating under the former provider was Good in October 2018. This explanation was written from the published report of 19 January 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
3 rated inspections over 4 years: the service has held its Good rating throughout.
- February 2023Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2022Requires improvementdown from GoodSafe: Requires improvementResponsive: GoodWell-led: Requires improvement
- October 2018GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2020
Registered with the Care Quality Commission on 10 March 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Ealing
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 £980 to £1,300 a week. 77 can care for a couple. 11 years' experience on average.
“I can truly say that Peter always put Dad at the centre of everything and I know that they found a great friendship in difficult times.”
“She has an unusual combination of kindness and firmness, is quite unflappable, physically strong, extremely savvy”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.