CQC report explained · a residential care home
What the CQC found at Elms House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks had been assessed and managed, medicines were given on time, staffing was sufficient and infection control was safe. They also found that earlier fire safety problems had been addressed.
- Effective?
- Good
- Not assessed in this focused inspection.
- Caring?
- Good
- Not assessed in this focused inspection.
- Responsive?
- Good
- Not assessed in this focused inspection.
- Well-led?
- Requires improvement
- The culture was positive and joint working had improved, but oversight of some health and safety checks was incomplete. Audit actions were not always documented or tracked.
What inspectors found, July 2023
Rated Good overall; inspectors found safe, supportive care and clear improvements, but leadership and quality monitoring still required improvement.
This was an unannounced focused inspection on 14 and 16 June 2023. One inspector spoke with a person using the home, a witness, eight staff members and two mental health professionals. They reviewed one care plan, medicine records, audits, policies and procedures.
The home was rated Good for Safe. People had suitable safety plans, received medicines on time, and infection control was managed safely. Problems found at the previous inspection, including fire safety actions and personal emergency evacuation plans, had been addressed.
The home remained Requires Improvement for Well-led. Managers had made substantial progress, but some safety checks were not fully overseen and audit actions were not always recorded in a plan. The overall rating was Good, and the home was no longer in breach of the previous Regulation 12 requirement.
Improved safety
The home had addressed important safety problems found at the previous inspection, including fire safety actions and evacuation plans.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 12.” from the report
Medicines
People received medicines on time from trained staff. The earlier practice of staff preparing medicines for people to take away had stopped.
“People received their medicine on time by staff who were trained in safe administration.” from the report
Positive culture
Staff understood the rehabilitation approach and were focused on helping people achieve good outcomes.
“The culture in the home was positive and focussed on supporting people to achieve good outcomes.” from the report
Joint working
The home worked more closely with the mental health trust, with clearer shared processes and plans for further staff training.
“There was clear evidence of the service working with others in a collaborative and constructive way.” from the report
Incomplete oversight of safety checks
needs fixingThe landlord carried out some checks, but the home did not have full oversight of every area needed, including window restrictors. Immediate action was taken after inspectors raised this.
“We found these did not include areas such as window restrictors.” from the report
Audit actions not consistently tracked
needs fixingAudits were carried out, but some were irregular and their actions were not always recorded in an overall plan. This made it harder to monitor whether improvements were completed.
“Some audits were completed sporadically, and were not all used to their potential.” from the report
Limited provider-level checks
needs fixingInspectors found there had not been a provider-level quality audit for some time. The provider was therefore relying on information from the home rather than checking the service directly.
“There had not been a provider level quality audit for some time, meaning the provider was reliant on what they were being told as opposed to seeing for themselves.” from the report
- 01How do you now make sure all landlord health and safety checks, including window restrictors, are completed and recorded?
- 02What overall action plan do you use to track findings from all audits through to completion?
- 03How often will senior managers visit the home and carry out provider-level quality checks?
- 04How will you use the medicines audit tool to identify and prevent possible medicine errors?
- 05What further training will staff receive from the local Mental Health NHS Trust?
This was a focused inspection of Safe and Well-led, including infection prevention and control under Safe; Caring, Effective and Responsive were not rated. This explanation was written from the published report of 28 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, November 2018
Elms House was rated Requires Improvement; inspectors found kind, personalised care but important fire safety, medicines and management checks were not reliable enough.
This was an unannounced comprehensive inspection on 19 September 2018, followed by an announced visit on 12 October to confirm information. Inspectors spoke with people living there and staff, and checked care plans, medicines, staff records, policies, audits and incident records.
The home was rated Good for Effective, Caring and Responsive. People were treated with kindness, involved in decisions, supported to become more independent and offered a wide range of activities. Their health needs, food and future plans were also supported.
Safe and Well-led were rated Requires Improvement. Fire risk actions had not all been completed, not everyone had a personal emergency evacuation plan, and some safety checks had been left unresolved. Medicines guidance and practice were inconsistent, and there was no registered manager in post at the time.
Kind and respectful support
People said staff listened and provided emotional support. Inspectors saw a relaxed atmosphere and staff respecting privacy.
“People were supported by staff who were caring and listened to their needs.” from the report
Personalised care
Care plans included people's backgrounds, goals and wishes. Support was reviewed with people and the wider professional team.
“People received care that was personalised to their needs.” from the report
Building independence
People were supported with cooking, laundry, finances, shopping and moving into flats on site at a pace that suited them.
“People were encouraged to be independent and manage as many aspects of their life as possible.” from the report
Activities and future planning
People could choose from activities at the home and in the community. They were also supported to plan for life after leaving.
“People were supported to access a wide range of activities both in the home and in the wider community.” from the report
Fire safety was not fully addressed
seriousOnly one person had a Personal Emergency Evacuation Plan. Actions from the 2017 fire risk assessment, including work relating to fire doors and warning and detection systems, had not been evidenced as complete.
“People were not consistently being kept safe in relation to their fire safety.” from the report
Medicines procedures were inconsistent
seriousThe policy did not cover medicines taken out of the home, staff practice varied, and some as-needed medicine instructions did not explain clearly when the medicine should be used.
“There was not enough guidance and detail about how people needed to be supported with their 'when required' medicines to ensure they had them as prescribed.” from the report
Cleaning products were left unattended
needs fixingCleaning products were seen in several unattended places. The management team said they should be locked away and addressed this immediately.
“This meant that people were at risk of harm due to the unsafe storage of substances hazardous to health.” from the report
No registered manager was in post
needs fixingThe previous manager had left and the new manager had not yet started. The deputy manager and managers from elsewhere in the organisation were overseeing the home during the transition.
“There was no registered manager in post.” from the report
- 01Have all people now got Personal Emergency Evacuation Plans, and have every action from the fire risk assessment been completed?
- 02How are medicines taken out of the home now risk assessed and recorded?
- 03How do you make sure instructions for as-needed medicines explain each person's symptoms and when the medicine should be given?
- 04Have the outstanding health and safety checks, including electrical testing, been completed and independently reviewed?
- 05Who is the registered manager now, and how is management oversight checking that safety actions stay completed?
This was an unannounced comprehensive inspection of the home, followed by an announced visit to confirm information; it was the first inspection at this location since a change of provider. This explanation was written from the published report of 17 November 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 Elms House
2 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- July 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2018Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2017
Registered with the Care Quality Commission on 1 March 2017.
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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