CQC report explained · a residential care home
What the CQC found at Elmcroft
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment, suitable safeguarding arrangements and safe medicine management. They also found infection control measures were in place.
- Effective?
- Good
- This area was not inspected during this visit. Its previous rating was carried forward.
- Caring?
- Good
- This area was not inspected during this visit. Its previous rating was carried forward.
- Responsive?
- Good
- This area was not inspected during this visit. Its previous rating was carried forward.
- Well-led?
- Good
- Managers promoted a positive, person-centred culture and reviewed incidents and improvements. Inspectors noted that the governance system was being made more robust.
What inspectors found, July 2023
Rated Good; inspectors found people were safe, supported with dignity and choice, and the home was well-led, with some records and systems still being reviewed.
Inspectors visited unannounced on five days between 19 June and 3 July 2023. They met one person, contacted two relatives, spoke with managers and staff, and checked care, medicine, staff and management records.
They found enough staff, safe medicine arrangements and suitable infection control. Staff understood safeguarding and supported people with their choices, independence, communication and everyday goals.
The home was rated Good overall. Safe and Well-led were both rated Good. The other three areas were not inspected during this visit, so their previous ratings were used to calculate the overall rating.
Choice and independence
People were supported to make decisions, use their strengths and achieve their goals. Staff communicated in ways that met individual needs.
“People were supported to have maximum possible choice, control and independence.” from the report
Kind and respectful care
Inspectors found that staff provided compassionate care and respected people's privacy, dignity and individual needs.
“Staff protected and respected people's privacy and dignity.” from the report
Enough suitable staff
The report says staffing levels were sufficient during the day and night, allowing staff to meet needs and spend meaningful time with people.
“There were enough staff to safely care for people.” from the report
Safe medicines
Staff were trained and assessed as competent to give medicines. Checks were carried out to keep records accurate.
“People's medicines were managed in a safe manner.” from the report
Positive leadership
Managers put people's needs and wishes at the centre of the service and involved people and families in care discussions.
“The registered managers promoted a positive, person-centred culture.” from the report
Risk assessments still being improved
needs fixingRisk assessments were detailed, but managers were still working with staff to make sure all potential risks were planned for effectively.
“The risk assessments were detailed and the manager was currently working with staff to ensure they effectively planned for all potential risks.” from the report
Capacity records under review
needs fixingManagers were reviewing capacity assessments and best-interests records to make sure they were accurate and specific to each decision.
“The registered managers were in the process of reviewing people's care records to ensure all capacity assessments and 'best interests' documents were decision specific and accurate.” from the report
Governance system being updated
minorManagers believed the existing system for checking quality needed updating and were creating a more robust system.
“They were currently in the process of creating a more robust governance system, as they felt the existing one needed updating.” from the report
- 01Have all risk assessments now been updated to cover every potential risk?
- 02Have the reviews of capacity assessments and best-interests records been completed?
- 03What changes have been made to the governance system since the inspection?
- 04How are you checking that staff have enough time to support each person with meaningful activities and goals?
- 05What were the previous ratings for Effective, Caring and Responsive, and when will these areas next be reviewed?
This was a focused inspection of Safe and Well-led; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 15 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.
What inspectors found, June 2018
Elmcroft was rated Good; inspectors found safe, caring and personalised support, with some records and staff review processes needing improvement.
This was a comprehensive, announced inspection carried out over three visits in April 2018. The inspector spoke with people living in the home, managers, support workers, a relative and other professionals. They also reviewed care, medicine, recruitment, training and management records, and observed staff supporting people.
The home supported three people with learning disabilities. Inspectors found enough staff, safe medicine arrangements, suitable accommodation and appropriate risk controls. People were supported to make choices, stay healthy, build independence, take part in activities and maintain relationships.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. This was the same overall rating as the previous inspection in January and February 2016. Inspectors identified improvements needed to the consistency of care records, recording staff supervision and appraisals, and the quality assurance system.
People felt safe
People and a relative said they felt safe. Inspectors found enough staff on duty and a consistent staff team who knew people's needs.
“People told us they felt safe and there were sufficient staff to meet people's needs.” from the report
Safe medicines support
Medicines were stored and given safely. People who wanted to manage their own medicines were supported to do so with assessments and checks.
“We found appropriate arrangements were in place for the safe administration and storage of medicines.” from the report
Choice and independence
People were supported to make choices, prepare meals, use the community, build skills and take part in work, volunteering and activities.
“People had choice and control of their lives and staff supported them in the least restrictive way” from the report
Kind and respectful care
Staff treated people with dignity and respect and supported their emotional needs and communication. Inspectors saw positive relationships between staff and people.
“We observed staff and people who used the service interacting and saw that staff treated people with dignity and respect” from the report
Person-centred culture
Managers and staff aimed to make the home feel like people's own home. Feedback from people, relatives and professionals was positive.
“Comments from people, relatives, staff and visiting healthcare professionals indicated there was a positive, person centred culture within the service.” from the report
Staff reviews were not fully recorded
needs fixingSome supervision discussions were not recorded, and staff appraisals had not yet taken place. Managers had started a process to improve this.
“Some of the discussions that took place were documented; however, both staff and the registered managers told us that meetings took place more frequently but where not always recorded.” from the report
Care plans needed updating
needs fixingSome care files were difficult to use because their styles varied and information had been updated by hand. A review of the files had begun during the inspection.
“The styles and content of files varied and some files were updated several times by hand, meaning information could be difficult to locate immediately.” from the report
Quality checks needed minor updates
minorThe quality assurance system needed to cover feedback from other agencies more fully and be more robust. The provider updated it during the inspection.
“This required minor updates to ensure it covered all aspects of feedback from other agencies and was robust.” from the report
- 01Have all care plans and risk assessments now been moved into a clear, consistent format?
- 02Are staff supervisions and appraisals now completed and recorded for every member of staff?
- 03How do you check that staff can quickly find the latest information about each person's needs and risks?
- 04What changes were made to the quality assurance system after the inspection?
- 05How will you support my relative's preferred activities, relationships, independence and community involvement?
This was a comprehensive inspection covering all five CQC questions, and the Good ratings remained unchanged from the previous inspection. This explanation was written from the published report of 6 June 2018 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 Elmcroft
3 rated inspections over 7 years: the service has held its Good rating throughout.
- July 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2018Goodstayed GoodSafe: GoodWell-led: Good
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- June 2011
Registered with the Care Quality Commission on 21 June 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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47 live-in carers within about an hour of County Durham
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Most charge £960 to £1,210 a week. 42 can care for a couple. 10 years' experience on average.
“Petty introduced herself to Mum every time she was caring for her and responded very quickly to Mum if she was distressed in the night.”
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