CQC report explained · a residential care home
What the CQC found at Elmfield House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risks were assessed, medicines were safely managed, staffing levels were sufficient and the home was clean.
- Effective?
- Good
- Care was based on people's needs and preferences. Staff supported nutrition, worked with health professionals, followed the Mental Capacity Act and received training and supervision.
- Caring?
- Good
- People and relatives spoke positively about staff. Inspectors saw people treated with dignity and supported to make choices and remain independent.
- Responsive?
- Good
- Care plans were detailed, personalised and regularly reviewed. People were supported with activities they enjoyed and received compassionate end of life care.
- Well-led?
- Good
- People, relatives and staff spoke positively about the management. The home used audits, meetings, complaints and incidents to identify improvements, although three required DoLS notifications had not been submitted before the inspection.
What inspectors found, April 2019
Rated Good; inspectors found safe, kind and personalised care, but three required notifications had not been submitted on time.
This was a planned comprehensive inspection on 24 January 2019. Inspectors spoke with people, relatives, staff, the manager and other workers. They reviewed care plans, risk assessments, medicines records, staff files, audits, incidents, complaints and meeting records.
The home was providing personal care for 17 older people, including people living with dementia, mental health conditions and physical health needs. Inspectors found people were safe, treated with kindness and involved in decisions about their care. Care plans were detailed and personalised, medicines were managed safely, and staff worked well with health professionals.
The home was clean and had enough staff. People and relatives spoke positively about the food, activities and atmosphere. Inspectors found good leadership, regular checks and evidence of improvements since the previous inspection.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Three required notifications about approved Deprivation of Liberty Safeguards had not been sent before the inspection, but the provider sent them immediately afterwards.
Safe medicines
Inspectors found that medicines were stored securely, checked regularly and given by trained staff. The records they reviewed had no gaps.
“Medicine administration records were completed accurately with no gaps.” from the report
Kind and respectful staff
People and relatives gave strong positive feedback about staff. Inspectors saw staff creating a warm atmosphere and respecting people's privacy and dignity.
“People and relatives gave consistently positive feedback about the caring nature of the staff who supported them.” from the report
Personalised care
Care plans included people's needs, interests and preferences. Staff knew what mattered to people and updated plans when needs changed.
“People had detailed care plans which reflected their needs as well as their interests and preferences.” from the report
Learning and improvement
The provider had made changes since the previous inspection, including improvements to the building, gardens, health and safety checks, and monitoring of incidents and complaints.
“The provider and registered manager had implemented a number of improvements since our last inspection.” from the report
Late regulatory notifications
needs fixingThree notifications about approved Deprivation of Liberty Safeguards had not been submitted before the inspection. The manager sent them immediately afterwards, so the report says the requirement was then met.
“We identified three instances where notifications had not been submitted following DoLS being approved.” from the report
- 01How do you now check that all required DoLS notifications are submitted on time?
- 02How often will my relative's care plan and risk assessments be reviewed, and how will you tell me about changes?
- 03How will you support my relative's particular interests, activities and independence?
- 04How do you check that medicines remain suitable if my relative becomes tired, unwell or their needs change?
- 05How would you work with health professionals if my relative needed wound care, mental health support or end of life care?
This was a planned comprehensive inspection covering all five CQC questions, and the report also explains that Well-led had improved from Requires Improvement in June 2016 to Good at a focused inspection in May 2017. This explanation was written from the published report of 3 April 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.
What inspectors found, June 2017
Elmfield House is rated Good; inspectors found strong management systems and confirmed that a previous registration problem had been fixed.
This was an unannounced, focused inspection on 3 May 2017. One inspector checked whether the provider had fixed a breach found in July 2016. The inspection looked only at how the home was led and managed.
The home had a registered manager in place. Inspectors found regular checks on areas such as medicines, care plans, infection control, safety and kitchen arrangements. Records of accidents and incidents were reviewed, and action was taken when needed.
People, relatives and staff said the home was friendly, caring and well run. People and relatives could give their views through meetings and surveys. The overall rating was Good, and the well-led question was also rated Good.
Registered manager in place
The previous problem with the manager's registration had been resolved. The manager had registered with the CQC before this inspection.
“The manager had successfully registered with the CQC on the 28 September 2016 for the provision of the regulated activity for Accommodation for persons who require nursing or personal care.” from the report
Regular quality checks
The home carried out checks at different intervals and recorded actions to address issues that were found.
“Quality assurance systems were in place to monitor the quality and running of service being delivered.” from the report
People could give their views
People and relatives attended regular meetings and could suggest changes to menus, activities and how the home was run.
“People and relatives told us they were provided with opportunities to have their say about how the home was run.” from the report
Supportive atmosphere
People, relatives and staff described the home as caring, friendly and welcoming. Relatives said they could visit at any time.
“The service had a positive culture that was person-centred, open, inclusive and empowering.” from the report
Inspectors raised no specific concerns in this report.
- 01How often are quality checks now carried out for medicines, care plans, infection control and safety?
- 02How are accidents and falls recorded and reviewed, and what action is taken when patterns are found?
- 03How can residents and relatives give suggestions or raise concerns, and how are the results acted on?
- 04Is the registered manager still in place and registered for the regulated activity?
- 05What activities and external visits are currently available to residents?
This was a focused inspection of Well-led only, to check whether the previous breach had been fixed; the report does not give separate ratings for Safe, Effective, Caring or Responsive. This explanation was written from the published report of 2 June 2017 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 Elmfield House
4 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- April 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2017Goodstayed GoodWell-led: Good
- September 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 30 December 2010.
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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Most charge £980 to £1,250 a week. 66 can care for a couple. 11 years' experience on average.
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