CQC report explained · a residential care home
What the CQC found at Elmleigh Homes Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were generally kept safe and there were enough suitable staff. However, health records, evacuation plans and medicine records were not always complete, and one head injury was not managed correctly.
- Effective?
- Good
- This question was not inspected during this focused visit.
- Caring?
- Good
- This question was not inspected during this focused visit, although inspectors observed kind and compassionate care.
- Responsive?
- Good
- This question was not inspected during this focused visit.
- Well-led?
- Requires improvement
- Management had improved the service and met previous breaches, but audits did not always lead to timely action. Care plans and risk assessments were still not consistently detailed or up to date.
What inspectors found, March 2022
Rated Requires Improvement and no longer in special measures; inspectors found improved care but incomplete health records and weak checks remained.
This was an unannounced focused inspection. Inspectors spoke with people and staff, observed care, and checked care plans, medicines, staff records and management records. They also looked at infection control.
The home had improved since its previous inadequate rating. People told inspectors they felt safe. There were enough staff, people received kind care, and staff supported their independence. The home was no longer in breach of regulations.
Important problems remained. Some care plans and risk assessments did not contain enough up-to-date information. One medicines record did not include allergies. The home had not always responded properly after a head injury, and its checks did not always identify problems.
The overall rating was Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were used in the overall rating.
Kind and respectful care
Inspectors found that people received compassionate care and that staff respected their privacy and dignity.
“People received kind and compassionate care. Staff protected and respected people's privacy and dignity.” from the report
Enough staff
There were enough staff, with suitable skills to meet people's needs and keep them safe.
“The service had enough staff numbers and skills of staff matched the needs of people using the service.” from the report
Support for independence
People were supported to make choices and take part in everyday tasks, including meals, domestic tasks and laundry.
“People were supported to be independent in some areas of their life, such as choosing their meals, completing some domestic tasks or doing their own laundry.” from the report
Improvement since the last inspection
The provider had addressed the previous breaches and the home was no longer inadequate or in special measures.
“During this inspection the provider demonstrated that improvements have been made.” from the report
Consistent staff team
Low staff turnover meant people were supported by staff who knew them well.
“Staff turnover was very low, which supported people to receive consistent care from staff who knew them well.” from the report
Incomplete health information
seriousSome diabetes records did not explain treatment goals, medicines, blood glucose monitoring or insulin therapy. High blood glucose readings were not always followed by recorded action.
“Records of people's health conditions had not always been fully completed.” from the report
Head injury response
seriousOn one occasion, staff did not seek medical advice or complete regular observations after a head injury. The person was not injured, but the response was not appropriate.
“On this occasion the person had not suffered any injuries, however medical advice was not sought, and regular observations were not completed.” from the report
Medicines allergy information
needs fixingOne medicines administration record did not include information about the person's allergies. This could increase the risk of an allergic reaction.
“We found one person's medicine administration records had not included their allergies.” from the report
Weak quality checks
needs fixingAudits did not always identify missing information or lead to improvements quickly. Some care plans and risk assessments were out of date.
“Audits were completed by the registered manager; however, they were not always used to implement and drive improvement in a timely manner.” from the report
Refurbishment still needed
minorSome bathrooms and communal areas needed improvement. The provider had a refurbishment plan but had not set timescales for completing it.
“The registered manager told us that there was a plan for future refurbishment, however there were no timescales when this would be completed.” from the report
- 01What has been changed to make sure diabetes records include treatment goals, medicines, monitoring and insulin information?
- 02How will you make sure every person's emergency evacuation plan reflects their current mobility and support needs?
- 03What is your current process for responding to head injuries, including when medical advice and regular observations are required?
- 04How do you check that medicines records include allergies and that audits identify missing information?
- 05What are the timescales for refurbishing the bathrooms and communal areas?
This was a focused inspection of Safe and Well-led, mainly checking a previous Regulation 12 Warning Notice; the other ratings carried over from the previous inspection. This explanation was written from the published report of 31 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, November 2021
Elmleigh Homes Limited is rated Inadequate and in special measures; inspectors found serious infection-control and leadership failures.
Inspectors made an unannounced, focused inspection visit on 29 September 2021. They looked only at Safe and Well-led because concerns had been raised about infection control and following COVID-19 guidance. They spoke with five people and four staff, and reviewed care, medicines, recruitment and management records.
The home was not following government guidance on PPE, COVID-19 testing, visitor checks, shielding and social distancing. Inspectors also found poor cleanliness and repair, including mould, damaged paintwork, cobwebs, a broken window and unsafe furniture and window restrictors. Medicines were given as prescribed, but some records were incomplete.
The home was rated Inadequate for Safe and Well-led. The overall rating changed from Good at the previous inspection, published on 15 February 2019. The home was placed in special measures, meaning CQC said it would monitor the service and re-inspect to check for significant improvement.
People felt safe
People told inspectors they felt safe. Staff understood how to recognise and report abuse.
“People told us they felt safe living at the service.” from the report
Enough staff
Inspectors found there were enough staff to meet people's needs. Staff had training, induction and opportunities to work alongside experienced colleagues.
“People were supported by sufficient staff to meet their needs” from the report
Independence
People were encouraged to learn life skills, make choices and take part in activities. Inspectors saw that people's rooms reflected their personal preferences.
“People were encouraged to be independent, learn life skills and were empowered to achieve positive outcomes.” from the report
Partnership working
The home worked with health and care professionals, including GPs, district nurses and speech and language therapists.
“There was evidence the service worked in partnership with other professionals.” from the report
COVID-19 infection control
seriousStaff did not wear the required surgical masks and testing was not carried out in line with government guidance. Visitor symptom checks and measures for people at particular risk were also not in place.
“Staff did not wear required surgical masks.” from the report
Unsafe environment
seriousInspectors found poor cleanliness and repair. Large furniture was not securely fixed, and some first-floor windows did not have restrictors, creating a risk of falls.
“We found some windows on the first floor did not have restrictors in place and they could be wide open.” from the report
Weak management checks
seriousThe home's audits did not identify problems that inspectors found, including a broken window, a broken electric socket and poor decoration. Earlier infection-control concerns had not been acted on.
“The provider's own governance monitoring systems were not effective in identifying issues and concerns.” from the report
Medicines records
needs fixingPeople received their medicines as prescribed, but the opening dates of liquid medicines were not recorded. This could make it difficult to check whether medicines were still suitable to use.
“We found liquid medicines had been in use, however information when the liquid medicine bottle was opened was not recorded.” from the report
Recruitment records
minorRecruitment checks were completed, but interview notes were missing from two of the four staff files reviewed.
“There were no interview notes in two staff files we looked at.” from the report
- 01What has been done to ensure staff wear the required PPE and complete the COVID-19 tests recorded in the report?
- 02Have all first-floor windows been fitted with working restrictors, and has furniture been securely fixed to walls?
- 03What repairs and cleaning work has been completed in the bathrooms, bedrooms and communal areas?
- 04How are managers now checking that infection-control risks, repairs and other safety problems are identified and acted on?
- 05What changes have been made to medicines records, including recording when liquid medicines are opened?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 5 November 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 Elmleigh Homes Limited
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- March 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2021Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- February 2019Goodstayed GoodSafe: GoodWell-led: Good
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 7 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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