CQC report explained · a residential care home
What the CQC found at Elm Park Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2021
Elm Park Lodge is rated Good; inspectors found safe, kind and well-managed care, with earlier medicines and recruitment problems improved.
This was a focused, announced inspection on 10 February 2021. Two inspectors spoke with people, managers and staff, observed daily care, checked the building and lunch, and reviewed medicines, recruitment, care records, risks, incidents and quality checks. They also contacted relatives and health and social care professionals after the visit.
The home was rated Good for Safe, Caring and Well-led. Inspectors found people felt safe, staff were kind, medicines were managed safely, recruitment checks were completed and there were enough staff. They also found the home had managed a recent COVID-19 outbreak effectively and worked well with health professionals.
The previous inspection had rated the service Requires Improvement because medicines and recruitment were not always safe. The report says these problems had been addressed and the home was no longer breaching regulations. This inspection did not look at Effective or Responsive, so earlier ratings for those areas were carried forward into the overall rating.
Medicines were safer
Inspectors found no medicines errors when checking five medicine stocks against records. The home had reduced the number of staff giving medicines and carried out regular audits.
“At this inspection we had no concerns regarding the management of medicines. We checked five medicine stocks checked against MARs, there were no errors.” from the report
Kind relationships
People and relatives praised the staff. Inspectors saw warm interactions and found that staff understood people's needs and routines.
“People and their relatives praised the service provided, and told us staff were kind and caring to them.” from the report
COVID-19 response
The home managed a recent outbreak through isolation, zoning, testing and dedicated staff. Families were kept informed and communication with relatives continued.
“There had been a recent outbreak of COVID-19 at the service, and this had been managed effectively through a mixture of isolating people, zoning and use of specific staff to support positive people.” from the report
Organised management
The home had a planned programme of audits covering areas such as medicines, infection control, care plans and recruitment. Actions were recorded and followed up.
“Audits were detailed and taking place regularly. We could see that actions were identified, and it was noted when these were completed.” from the report
Family involvement
People and families were asked for their views about care, menus and activities. Relatives said they were kept updated about changes in health and wellbeing.
“Family members told us they were kept up to date with their relatives' changes in health and well-being and that relationships with the staff and management were very positive.” from the report
PPE was not always used correctly
minorThe majority of staff were observed using protective equipment correctly, rather than all staff. Managers sent a reminder after the inspection about wearing it correctly.
“We observed the majority of staff using PPE appropriately to prevent the risk of cross infection.” from the report
- 01How do you check that every member of staff wears PPE correctly, and what action is taken if they do not?
- 02How often are medicines audited now, and how would you tell families if an error was found?
- 03What has changed in staff recruitment checks since the previous inspection?
- 04How are people being supported to return to their usual hobbies, activities and community access after COVID-19 restrictions?
- 05What were the previous ratings for Effective and Responsive, which were not examined during this inspection?
This was a focused inspection of Safe, Caring and Well-led; Effective and Responsive were not inspected and their previous ratings were carried forward into the overall rating. This explanation was written from the published report of 9 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.
What inspectors found, October 2019
Rated Requires Improvement; inspectors found kind, person-centred care but unsafe medicines management and recruitment checks.
This was an unannounced inspection on 18 September 2019. Inspectors spoke with people living in the home, staff, managers, health and social care professionals and family members. They observed daily life, checked the building, medicines, care records, staffing and complaints.
People were described as happy and safe, and staff were kind and caring. Care was personalised, people were supported to access health services, and activities took place both in the home and in the community. The home had enough staff to meet people's needs.
Medicines were not always managed safely. Inspectors found two errors when checking seven medicine stocks against records, and there was not always guidance for staff about when to give as-required medicines. Recruitment checks were also not always completed safely.
The overall rating was Requires Improvement. Effective, Caring and Responsive were rated Good. Safe and Well-led remained Requires Improvement. The home had received Requires Improvement at the previous two inspections, and the report says it had held this rating for three consecutive inspections.
Kind and caring staff
People and families described staff as kind and caring. Inspectors saw warm and compassionate interactions.
“People told us they were happy living at the service and staff were kind and caring to them.” from the report
Personalised care
Care plans covered people's mental health, personal care, finances, safety, interests and hobbies. People and professionals contributed to the plans.
“People's care plans were detailed, comprehensive in scope and up to date.” from the report
Good health support
The home worked with GPs, psychiatrists and other mental health professionals. Families and professionals praised how staff supported complex needs.
“The service was effective in supporting people to access healthcare services to maintain good physical and mental health.” from the report
Activities and independence
People were supported to take part in activities, visit places in the community and do tasks for themselves where possible.
“The provider ran several activities at the service including art classes, exercise classes, movie nights and cooking classes.” from the report
Medicines records and guidance
seriousInspectors found two errors when checking seven medicine stocks against records. There was also no specific guidance for staff on when to give some as-required medicines. This was a breach and placed people at risk of harm.
“Of seven medicine stocks checked against MARs, we found two errors.” from the report
Recruitment checks
seriousOne staff member worked for six weeks before the full DBS information was available. The home had not risk assessed the person at the time of inspection. This was a breach of the recruitment regulation.
“One staff member was employed at the service without their full Disclosure and Barring Service (DBS) details being available to the service.” from the report
Some risk records were incomplete
needs fixingA new person's risk assessment had not been completed at the inspection, although staff understood the risks. The manager completed the documents for high-risk situations after the inspection.
“We found one new person's risk assessment had not been completed despite two clear risks on admission.” from the report
- 01What changes have been made to the medicines system introduced after this inspection?
- 02How do you now check medicine stocks against the medicine administration records?
- 03How do you make sure staff have clear guidance about when to give as-required medicines?
- 04Are all current staff recruitment and DBS checks complete and properly risk assessed?
- 05How do you monitor whether the improvements required after this inspection have been fully completed?
This was an unannounced planned inspection covering all five CQC questions, with checks of care, staffing, medicines, records, the building and management systems. This explanation was written from the published report of 24 October 2019 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 Park Lodge
5 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- March 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2019Requires improvementstayed Requires improvementSafe: Requires improvementCaring: GoodWell-led: Requires improvement
- August 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 January 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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At least 100 live-in carers within about an hour of Barnet
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. 83 can care for a couple. 12 years' experience on average.
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