CQC report explained · a nursing home
What the CQC found at Elm Lodge Nursing and Residential 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, July 2023
Rated Requires Improvement; inspectors found safe, kind care, but meaningful activities, mealtime support and some care planning were not reliable enough.
Inspectors visited without notice on four dates between 19 April and 18 May 2023. They spoke with people, relatives, staff and health professionals, observed care, and checked care, medicine, recruitment and quality records.
The home was rated Good for Safe and Caring. Inspectors found people were protected from abuse, risks were assessed, medicines were stored safely, and staff usually treated people with kindness, dignity and respect.
The home was rated Requires Improvement for Effective, Responsive and Well-led. People were often bored and did not always receive meaningful company or enough support during busy mealtimes. Some medicine, consent and person-centred care records also needed improvement.
The overall rating Requires Improvement means the home was not consistently meeting people's needs, although inspectors also found positive work by the new provider and an action plan for improvement.
Kind and respectful staff
People and relatives were positive about the staff. Inspectors observed that people appeared comfortable and relaxed with them.
“People were supported by a kind and compassionate staff team who had got to know people as individuals.” from the report
Safeguarding and risk management
Staff understood how to recognise and report abuse. Individual risks were assessed, reviewed and made available to staff through the electronic care system.
“People had risk assessments in place to meet their individual needs.” from the report
Support with health needs
People were supported to attend health appointments and staff worked with other professionals to meet people's needs.
“People were supported to see health professionals and to live healthy lives.” from the report
End of life support
People's end of life wishes were recorded when they wanted to discuss them. Staff had training and worked with specialist professionals to support a dignified death.
“People were supported with dignity and respect at the end of their lives.” from the report
Too little meaningful time
seriousPeople were often bored or lonely and staff did not have enough time for informal conversation. The report says this was a breach of the person-centred care regulation.
“People told us they were often bored and had little to do except watch the wall or watch other people facing them in the lounge.” from the report
Support at mealtimes
needs fixingStaff were not always available to notice when people needed extra help during busy periods. Inspectors saw three people who did not receive the support they needed.
“We observed 3 people not receiving the support they required at this time.” from the report
Incomplete medicine care plans
needs fixingSome care plans did not explain risks from high-risk medicines or when palliative medicines should be started.
“Medicine care plans were in place. However, these were not always person-centred.” from the report
Consent and restrictions
needs fixingNot all staff knew which people had restrictions or what those restrictions were. In one case, staff asked a relative's view before asking the person themselves.
“However, not all staff were aware of who had restrictions and what the restrictions were for.” from the report
Dementia-friendly environment
minorThe home had limited signage, decoration and communal space to support people living with dementia or different activities.
“The environment did not currently support people living with dementia, but the new provider was making improvements to the premises to further improve people's care and support.” from the report
- 01What regular activities and informal conversations are now available for people who do not want entertainers or trips out?
- 02How do you make sure staff are available during mealtimes to notice and respond to people who need help?
- 03How have you improved care plans for high-risk medicines and palliative medicines?
- 04How do staff know which people have restrictions and how do you make sure the person's own views are sought first?
- 05What changes have been made to signage, communal areas and decoration for people living with dementia?
This was an unannounced inspection covering all five key questions, the premises, care and infection prevention and control; inspectors visited on three dates and completed other inspection work remotely. This explanation was written from the published report of 20 July 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.
Every inspection of Elm Lodge Nursing and Residential Home
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Elm Lodge Nursing and Residential Home →
- October 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- October 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2022
Registered with the Care Quality Commission on 18 January 2022.
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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