CQC report explained · a residential care home
What the CQC found at Elm Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm. Inspectors found good arrangements for safeguarding, risk management, medicines, infection control and learning from incidents, although recruitment difficulties and regular agency use were noted.
- Effective?
- Good
- Care plans were detailed and based on people's needs, wishes and goals. Staff had relevant training and supported people's health, communication, eating, decision-making and independence.
- Caring?
- Good
- This question was not inspected during this focused visit. The report says the rating from the last inspection was used for questions that were not inspected.
- Responsive?
- Good
- This question was not inspected during this focused visit. The report says the rating from the last inspection was used for questions that were not inspected.
- Well-led?
- Good
- Management and governance were effective, and staff and relatives said managers were supportive and approachable. This area improved from Requires Improvement at the last inspection.
What inspectors found, April 2022
Rated Good; inspectors found safe, kind and person-centred care, but staffing was a concern and this was a focused inspection.
The inspection took place without notice on 8 and 10 March 2022. One inspector spoke with people, staff, relatives and a health professional. They reviewed care plans, medicines records, recruitment files, training information and management records.
The home supported three people with learning disabilities or autistic spectrum disorder. Inspectors found that people were safe, treated with kindness and supported to make choices, stay healthy, use the community and follow their interests. Medicines, infection control, risk management and safeguarding were handled well.
This was a focused inspection of Safe, Effective and Well-led. All three areas were rated Good. Caring and Responsive were not inspected during this visit, so their previous ratings were carried forward. The overall rating stayed Good.
Choice and independence
Staff supported people to make choices, control their lives and take part in interests and activities in the local community.
“Right Support; Staff supported people to have the maximum possible choice, control and independence over their lives.” from the report
Kind and individual care
Staff understood people's communication, cultural and personal needs. Relatives spoke positively about the support provided.
“People received kind and compassionate care. Staff protected and respected people's privacy and dignity.” from the report
Safe medicines support
Staff followed safe systems for giving, recording and storing medicines. They also reviewed medicines and followed guidance intended to avoid over-medication.
“Staff followed systems and processes to administer, record and store medicines safely.” from the report
Improved leadership
Management systems were effective and staff felt able to raise concerns. The Well-led rating improved from Requires Improvement to Good.
“Governance processes were effective and helped to hold staff to account, keep people safe, protect people's rights and provide good quality care and support.” from the report
Recruitment and agency staffing
minorThe home had difficulty recruiting staff and used agency staff regularly. Staff expressed concern about staffing numbers, although inspectors found that support was in place and no one had been put at risk.
“Staff told us they felt concerned about staffing numbers, but all agreed that support was in place and no one had been at risk because of the staffing levels in the home.” from the report
Minor maintenance
minorSome small areas needed maintenance when inspectors visited. The work had already been booked for completion.
“Some small areas of the home needed maintenance and had been booked for completion at the time of our visit.” from the report
- 01How many permanent and agency staff are normally on duty for each shift?
- 02How do you make sure agency staff understand each person's needs, wishes and communication style?
- 03What progress has been made with the small maintenance jobs identified during the inspection?
- 04How are people's medicines reviewed, particularly medicines given as needed?
- 05How will families be involved in reviewing care plans and changes in people's needs?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 30 April 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, March 2021
Rated Good overall; inspectors found safe, kind care, but the home’s leadership and follow-up needed improvement.
This was the home’s first inspection since it registered. The visit was unannounced and took place on 21 January 2021. One inspector spoke with people, relatives and staff, and checked care records, medicines, safeguarding, complaints, staffing and quality checks.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found people were safe, received their medicines, had skilled support and were treated with dignity. People were supported to make choices, stay independent, keep relationships and take part in activities.
Well-led was rated Requires Improvement. People and relatives were not consistently involved in care plan reviews. Management did not always respond quickly to requests or work well with relatives and professionals. There was also not enough recorded learning from some safeguarding incidents, and no registered manager was in post.
Kind and respectful care
Staff treated people with kindness, dignity and respect. They supported people to make choices and remain as independent as possible.
“People and their relatives told us they felt well cared for by staff who treated them with respect and dignity” from the report
Skilled staff
Inspectors found staff were trained, competent and knowledgeable about people's changing needs. New staff received a comprehensive induction.
“People were supported by staff who were well trained and competent in their role.” from the report
Choice and activities
People were supported to choose activities at home and in the community, and to keep in contact with relatives during the pandemic.
“People were supported by staff to take part in activities that they chose, both within the home and in the community.” from the report
Medicines managed safely
Staff were trained and checked as competent to give medicines. Records showed people received medicines regularly and audits were completed.
“Medicines were managed to ensure people received them safely and in accordance with their health needs and the prescriber's instructions.” from the report
Care reviews did not involve families consistently
needs fixingPeople, relatives and representatives were not consistently involved in reviewing care plans. The acting manager said a structured review programme would be introduced.
“People and their relatives were not consistently involved in the review and development of care plans.” from the report
Slow responses to requests
needs fixingRelatives and professionals said management did not always respond promptly. One family request had remained unresolved for several months before the inspection raised it.
“Relatives and professionals linked to the service told us that management were not consistently responding to issues in a timely manner.” from the report
Leadership arrangements needed improvement
needs fixingThere was no registered manager in post. Inspectors also found that learning from some safeguarding incidents was not consistently recorded or discussed with staff.
“The provider did not have a registered manager in post.” from the report
Partnership working was inconsistent
needs fixingThe home did not always work promptly with relatives, health professionals and local authority teams. Professionals reported delays in receiving information about safeguarding incidents.
“We found the provider was not consistently working in partnership with people's relatives, health professionals, local authority departments and various groups and services within the community” from the report
- 01How are people, relatives and representatives now involved in care plan reviews?
- 02Who is currently responsible for management, and what is the progress of the application to become the registered manager?
- 03How quickly will you respond to relatives' requests and requests for information from professionals?
- 04How do you record and share lessons learned from safeguarding incidents with staff?
- 05How do you check that partnership working with relatives, health professionals and local authority teams is effective?
This was the first comprehensive inspection of the newly registered home, covering all five key questions and infection prevention and control arrangements. This explanation was written from the published report of 4 March 2021 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
2 rated inspections over a year: the service has held its Good rating throughout.
- April 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2021GoodSafe: GoodEffective: GoodWell-led: Requires improvement
- June 2020
Registered with the Care Quality Commission on 4 June 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.
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At least 100 live-in carers within about an hour of Dudley
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 £1,230 a week. 88 can care for a couple. 10 years' experience on average.
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
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