CQC report explained · a residential care home
What the CQC found at Elmhurst Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe, and inspectors found enough staff, suitable safeguarding arrangements, safe infection controls and generally safe medicine management. Some risk and medicine records were not complete or clear enough.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was used to calculate the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. The report nevertheless describes staff as kind and respectful.
- Responsive?
- Good
- This question was not inspected during this focused visit. Inspectors did identify that activities did not always meet people's differing needs.
- Well-led?
- Good
- The home had management systems, audits and regular communication with people, relatives and staff. Some minor problems had not been found through audits, but the manager acted promptly when inspectors raised them.
What inspectors found, March 2022
Elmhurst Residential Home rated Good overall; inspectors found safe, kind care, but activities and some records needed improvement.
This was an unannounced focused inspection on 15 February 2022. Inspectors looked mainly at Safe and Well-led. They spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and management records.
The home was rated Good for Safe and Well-led. People said they felt safe. Inspectors found enough staff, safe medicine systems, suitable infection controls and staff who were kind and respectful.
There were some weaknesses. Risk information was not always detailed enough in care plans. Some medicine records were unclear, and recruitment checks did not always include full employment histories. Activities did not always suit people's different abilities.
The previous rating was Requires Improvement, published in May 2021. The provider had completed an action plan, and inspectors found that improvements meant the home was no longer in breach of regulations. The overall rating changed to Good, but some other ratings were carried forward from the earlier inspection.
Enough staff
Inspectors saw enough staff to meet people's needs safely. People and relatives also said staff were available and supportive.
“Throughout the inspection we observed there to be sufficient staff available to meet people's needs safely.” from the report
Kind and respectful care
Staff spent time with people and supported them with dignity. Relatives also spoke positively about the care.
“We observed staff responding to people's needs with dignity and respect.” from the report
Clean and infection-safe
The home was clean, staff used protective equipment properly and infection control processes were in place.
“We observed the home to be clean. Daily cleaning processes were in place to prevent the spread of infections.” from the report
Activities were not personalised enough
needs fixingActivities did not always reflect people's different abilities, cognition or physical needs. The report recommends training and development so activities are more meaningful.
“Activities organised and delivered did not take into consideration people's different levels of cognitive abilities.” from the report
Some risk plans lacked detail
needs fixingSome identified risks were not linked to a detailed care plan. This could leave staff without all the information they need, although staff generally knew people well.
“This meant that care staff may not always have access to the required information to mitigate risk and keep people safe.” from the report
Medicine records were sometimes unclear
minorSome handwritten medicine entries did not have the required two signatures. Variable doses were not always recorded clearly, making stock checks difficult.
“This meant that it was difficult to reconcile certain stock levels to ensure people were receiving their medicines as prescribed.” from the report
Recruitment records were incomplete
minorChecks showed staff were suitable to work in the home, but full employment histories and gaps in employment were not always explored.
“We did find that a full employment history and gaps in employment were not always explored.” from the report
- 01How have you changed activities so they suit people with different cognitive, communication and physical abilities?
- 02How do you check that every identified risk has a detailed and up-to-date care plan?
- 03What checks now make sure handwritten medicine entries have the required signatures and variable doses are recorded clearly?
- 04How do you make sure every new recruit has a complete employment history, including explanations for gaps?
- 05Which ratings were carried forward from the previous inspection, and when will all five areas next be reviewed?
This was an unannounced focused inspection of Safe and Well-led, including infection control; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 30 March 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, May 2021
Elmhurst Residential Home was rated Requires Improvement because staffing levels were not always enough and management systems needed strengthening.
This was an unannounced focused inspection on 11 March 2021. Inspectors reviewed Safe, Effective and Well-led. They spoke with people, relatives, staff and health professionals, observed care and mealtimes, and checked care, medicines and management records.
The main problem was staffing. At times, people waited for help, had little company and did not receive enough support at mealtimes. The provider increased afternoon and evening staffing immediately, and increased night staffing two weeks later.
Inspectors found caring staff, safe medicines systems, good hygiene and suitable infection precautions overall. However, some staff did not wear masks correctly, the infection control policy was out of date, and the menu did not fully reflect people's cultural preferences.
The overall rating fell from Good to Requires Improvement. Safe and Well-led were rated Requires Improvement, while Effective remained Good. The home had a breach of Regulation 18 about staffing, and CQC asked for an action plan and planned to monitor progress.
Kind and compassionate staff
Inspectors saw caring, person-centred interactions. People and relatives gave positive feedback about staff kindness and knowledge of individual needs.
“We observed people were cared for by staff who were caring and compassionate.” from the report
Medicines generally managed safely
Staff explained medicines and gave people time to take them. Medicines audits and staff competency checks were in place.
“People received their medicines safely as prescribed. There were suitable systems and processes in place to manage medicines safely.” from the report
Good care and professional working
Staff knew people's health needs and preferences, supported medical appointments and worked constructively with health and social care professionals.
“Health and social care professionals told us that the home worked well with them and acted on their recommendations for improvement.” from the report
Clean environment and visiting precautions
The inspected rooms were clean, with handwashing facilities, hand sanitiser and PPE stations. Visiting precautions included testing and temperature checks.
“All rooms inspected were clean and had suitable handwashing facilities.” from the report
Not enough staff at some times
seriousStaffing was not always sufficient. People sometimes waited for help, had little stimulation and did not receive enough support with eating or going to bed.
“Staffing levels were not always sufficient to meet people's needs.” from the report
PPE was not always worn correctly
needs fixingMost staff were wearing masks incorrectly during the inspection. The provider said it addressed this with information, videos and checks after the visit.
“Although staff wore aprons and masks, plus gloves for personal care, most staff were wearing their masks incorrectly.” from the report
Management oversight needed strengthening
needs fixingThere had been no CQC-registered manager for a year. One incident notification was also missed, although it was sent after the inspection.
“The home has not had a manager registered with CQC for a year.” from the report
Some records were incomplete
needs fixingThere were no medicine profiles explaining people's conditions and medicines. One allergy was missing from a medicines record, although this was corrected and no harmful medicine had been given.
“There were no medicines profiles for people explaining their medical conditions and what each medicine was for.” from the report
Communication was uneven
minorMost relatives felt informed, but some wanted more regular updates and had not received recent feedback questionnaires.
“One relative told us they were not receiving updates as often as they would like on their relative's wellbeing.” from the report
- 01What staffing levels are now in place in the afternoon, evening and at night, and how are they matched to people's needs?
- 02How do you check that people receive enough support at mealtimes and are not left without company or stimulation?
- 03Has the manager now applied for or obtained CQC registration, and how are management checks being monitored?
- 04How do you ensure staff wear PPE correctly and follow the updated infection control guidance?
- 05How are people's cultural and dietary preferences recorded and reflected in the menu?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 18 May 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 Elmhurst Residential Home
9 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- March 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- April 2019Goodup from Requires improvementSafe: Requires improvementEffective: GoodWell-led: Good
- September 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- July 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2016Requires improvementstayed Requires improvementSafe: Requires improvement
- August 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- November 2013
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.
- March 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 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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