CQC report explained · a residential care home
What the CQC found at Elm Tree House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, August 2022
Rated Requires Improvement; inspectors found safe care but gaps in activities, independence, records and quality checks.
Inspectors visited the home without notice on 18, 20 and 25 July 2022. They spoke with five people, eight staff and relatives, and reviewed care plans, recruitment files, audits and other records.
The home was rated Good for Safe. Medicines, infection control, safeguarding and emergency plans were generally managed well. However, inspectors saw too much thickener added to one person's drink, and some creams had not been dated when opened.
Responsive and Well-led were rated Requires Improvement. People were not always supported to go out, follow hobbies or use funded one-to-one hours. Records and audits did not reliably show what support people received or identify these shortfalls.
The overall rating changed from Good at the previous inspection, published on 20 January 2018, to Requires Improvement. The report says the provider must send an action plan and that CQC will monitor progress.
Safeguarding
Staff understood how to recognise and report abuse. Potential safeguarding concerns were shared with the local authority when needed.
“Staff spoke confidently about how they would identify abuse and what actions they would take if abuse was suspected or witnessed.” from the report
Medicines
Medicines were administered by trained staff, records were signed and medicines were stored safely.
“Medicines were managed safely.” from the report
Personal knowledge
Permanent and longstanding agency staff knew people well and could describe their support needs in a person-centred way.
“Permanent staff knew people and their support needs.” from the report
Infection control
Inspectors were assured that the home had arrangements for preventing and managing infection outbreaks, including the use of protective equipment and testing.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Activities and independence
seriousRecords did not show that people were consistently supported to go out, pursue interests or use funded one-to-one hours. This was a breach of Regulation 9.
“The provider failed to ensure people received consistent support to pursue their hobbies, interests and that promoted their independence.” from the report
End of life planning
needs fixingOnly one person had an end of life care plan, and it was incomplete and contained conflicting information.
“We reviewed the care plan and found it was incomplete and contained conflicting information.” from the report
Quality checks and records
seriousAudits did not identify missing daily records, missed one-to-one hours or the continuing lack of a second meal option. This was a breach of Regulation 17.
“The provider failed to consistently and effectively operate governance systems to identify shortfalls, errors and omissions.” from the report
Staffing and outings
needs fixingRelatives said there were not enough staff and that people could not always go out because there were too few drivers. The provider was recommended to review how staffing levels were assessed.
“They've been really short staffed, and no one drives so she doesn't go out” from the report
Safe use of thickener
seriousInspectors observed a member of staff adding too much thickener to a drink for a person at high risk of choking.
“Despite this, we observed a member of staff adding too much thickener to the person's drink.” from the report
- 01How will you make sure my relative receives the activities, outings and community access recorded in their care plan?
- 02How are funded one-to-one hours recorded and checked so that missed hours are identified and made up?
- 03What has been done to make sure end of life care plans are complete, accurate and free from conflicting information?
- 04How are daily records and audits now checked for missing information about meals, feelings and personal care?
- 05What action has been taken to prevent incorrect amounts of thickener being added to drinks?
This inspection covered Safe, Responsive and Well-led; Effective and Caring were not reported as inspected, and the ratings for the inspected areas at the previous inspection were used where applicable. This explanation was written from the published report of 17 August 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, April 2021
Inspected but not rated; inspectors found strong infection-control arrangements, but some laundry-area improvements were still needed.
This was an announced, targeted inspection on 11 March 2021. It looked at how the home prevented and controlled COVID-19 infections. The home supported six people at the time, although it could support eight.
Inspectors found hand cleaning, visitor checks, suitable protective equipment, testing, social distancing measures and extra cleaning. There was also a visiting room and support for people to keep in touch with relatives by video call.
The home was assured in most areas of infection control. However, inspectors were only somewhat assured about the layout and hygiene of the premises because the laundry floor was worn and laundry sideboards were cluttered.
The service was inspected but not rated. This means the report does not give an overall quality rating or a rated score for Safe, and it did not assess the other four questions.
Protective equipment and staff knowledge
Staff had infection-control training, suitable supplies of protective equipment and used it appropriately. Inspectors found staff understood how to protect people from infection.
“Staff were confident and knowledgeable about how to protect people from the risk of infection and the environment was clean.” from the report
Visiting and family contact
The home had a designated visiting room and a visiting procedure. Staff also helped people stay in contact with relatives through video calls.
“A visiting room was allocated for visits. There was a visiting procedure in place.” from the report
Cleaning and social distancing
The home had added cleaning of frequently touched surfaces and made changes to support social distancing.
“Additional cleaning had been implemented throughout the home.” from the report
Laundry floor
needs fixingThe laundry floor was worn and needed replacing. The provider had identified this and said action was being taken to resurface it.
“The laundry room floor required replacing as it was worn in areas, this had been identified by the provider and action was being taken to resurface the floor.” from the report
Clutter in the laundry
needs fixingClutter on the laundry sideboards could make effective cleaning difficult. The manager said storage boxes would be ordered.
“We also noted the laundry sideboards were cluttered in areas that would prevent effective cleaning.” from the report
Understanding of COVID-19 testing
needs fixingTwo people needed mental capacity assessments and best-interest decisions because they might not fully understand why testing was needed. The manager said this would be addressed.
“Mental Capacity assessments and best interest decisions were required for two people living at the home.” from the report
- 01Has the worn laundry-room floor now been resurfaced or replaced?
- 02Have storage boxes been provided so the laundry sideboards can be cleaned effectively?
- 03How are mental capacity assessments and best-interest decisions recorded when someone may not understand the reason for COVID-19 testing?
- 04What infection-control arrangements are currently used for visitors, protective equipment, testing and social distancing?
- 05How can residents currently keep in touch with relatives if face-to-face visits are restricted?
This was an announced, targeted inspection of infection prevention and control during the COVID-19 pandemic; the overall service and the Effective, Caring, Responsive and Well-led questions were not rated. This explanation was written from the published report of 21 April 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 Tree House
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- August 2022Requires improvementcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Inspected but not rated
- January 2018Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Good
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 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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