CQC report explained · a nursing home
What the CQC found at Elmsfield House Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that the home used PPE safely, managed visiting and admissions safely, carried out testing, and had measures to prevent and manage infection outbreaks.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, February 2021
Inspected but not rated; inspectors found good infection control and pandemic safety arrangements.
This was an announced, targeted inspection on 3 February 2021. It looked only at infection prevention and control arrangements during the coronavirus pandemic.
Inspectors found the home was clean, tidy and well ventilated. Staff used hand hygiene and personal protective equipment correctly. The home had enough protective equipment, regular cleaning checks, staff training and COVID-19 testing.
The home had plans for outbreaks and emergencies. Visiting arrangements, admissions, social distancing and support for relatives to keep in touch were managed in line with guidance.
The service was inspected but not rated. This means the report does not give a new overall rating or a full rating for all five areas of care.
Clean and well maintained
The home was clean, tidy and well ventilated. A designated team carried out cleaning, with checks on cleanliness and infection control.
“The home was clean, tidy and well ventilated.” from the report
Good infection control
Staff used hand hygiene and PPE correctly, and received training in infection control and managing COVID-19 outbreaks.
“We saw good hand hygiene and the correct process for putting on and removing personal protective equipment (PPE)” from the report
Enough protective equipment
The home had sufficient PPE for staff and visitors.
“The provider had ensured sufficient quantities of PPE were available for all staff and visitors.” from the report
Safe contact with relatives
The home supported relatives to visit safely and helped people stay in touch through video calls, newsletters and telephone calls.
“They had supported relatives to visit people safely using the secure visitors room” from the report
Pandemic planning
The home had contingency plans, reviewed staffing arrangements and carried out regular COVID-19 testing for staff and residents.
“The registered manager had clear contingency plans and applied local authority guidance” from the report
Inspectors raised no specific concerns in this report.
- 01What is the home's current overall CQC rating, since this inspection was not rated?
- 02How have your infection prevention and control arrangements changed since February 2021?
- 03How do you currently manage visits from relatives and help residents keep in touch?
- 04How often are staff trained and observed on hand hygiene and PPE use?
- 05What are your current arrangements for testing, vaccinations and managing an infection outbreak?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; it did not provide ratings for the other areas of care. This explanation was written from the published report of 20 February 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.
What inspectors found, May 2019
Elmsfield House Limited was rated Good; inspectors found safe, kind and personalised care, with some policies needing updating.
This was an unannounced inspection on 5 April 2019. Inspectors spoke with people living in the home, relatives, staff and a visiting professional. They also reviewed care records, staff files, audits and other records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough suitably skilled staff, safe medicines practices, kind care and good support with food, activities and health needs.
The home had improved from Requires Improvement at the previous inspection, published in April 2018. Inspectors recommended that the provider update all policies and procedures so they reflect current legislation.
Enough staff
Inspectors found enough staff with different skills to meet people's needs promptly and safely.
“there were adequate numbers of differently skilled staff on each shift to meet people's needs in a timely manner.” from the report
Safe medicines
Medicines were stored, given and checked safely by trained staff.
“Medicines were stored appropriately and administered by staff who had received the appropriate training” from the report
Kind and respectful care
Staff knew people well and supported their dignity, privacy and independence.
“Care provided to people respected their privacy, dignity and promoted their independence.” from the report
Activities and social life
People could choose from varied activities and use a dedicated social club building.
“there was a varied activity programme that people could partake in if they chose to.” from the report
Policies need updating
needs fixingSome policies and procedures did not refer to current legislation. Inspectors recommended that the provider review and update them.
“We found some polices and procedures did not make reference to current legislation.” from the report
Electronic records oversight
minorInspectors said the electronic records could better include all the information needed to oversee quality and safety.
“the electronic records could be further improved to include all of the oversight of the quality of the service.” from the report
- 01Which policies were out of date, and have all of them now been reviewed against current legislation?
- 02How do you make sure the electronic care records provide complete oversight of care quality and safety?
- 03As the registration now includes nursing care, what nursing support, staffing and clinical experience would be available if a resident needed it?
- 04How are people's care plans and electronic records checked to make sure they remain current and accurate?
- 05What activities are available for someone with dementia, and how are their personal interests and choices included?
This was an unannounced inspection covering all five rating areas, including the premises and care provided; at the time, no one was receiving nursing care. This explanation was written from the published report of 17 May 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.
Every inspection of Elmsfield House Limited
4 rated inspections over 4 years: the service has held its Good rating throughout.
- February 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- May 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2017Requires improvementdown from GoodSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- October 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
9 live-in carers within about an hour of Westmorland and Furness
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.