CQC report explained · a nursing home
What the CQC found at Elmwood Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2022
Inspected but not rated; inspectors found good infection-control arrangements but some PPE, cleaning records and visitor procedures were not consistently followed.
This was an announced, targeted inspection on 20 January 2022. It followed a COVID-19 outbreak and looked mainly at infection prevention and control, as well as staffing pressures.
The home had an up-to-date infection-control policy, regular audits, PPE supplies, staff training, COVID-19 testing and vaccination arrangements. Inspectors were assured about shielding, social distancing, safe admissions and managing outbreaks.
There were some shortfalls. A few staff were not wearing PPE correctly, cleaning records were incomplete, and the visitor infection-control process was not followed during the inspection. The manager said these issues would be investigated or addressed.
The overall service and Safe question were marked 'Inspected but not rated'. This was not a full inspection rating of the home.
Infection-control policy
The home had a current infection-control policy and carried out regular audits.
“Regular Infection prevention control (IPC) audits were undertaken.” from the report
PPE and staff training
Staff had PPE supplies and training on using it and preventing infection.
“Staff had access to supplies of PPE and had received training to ensure they used this correctly.” from the report
Testing and vaccination
Staff had regular COVID-19 testing and vaccinations, and the home met the vaccination requirement that applied at the time.
“All staff had regular testing for COVID-19, and all had received their vaccinations.” from the report
Managing visits
The home had assessed visitor risks and kept visits and video calls available.
“Risks in relation to visitors had been assessed and action taken to ensure visits were still in place at the service and through video calls.” from the report
PPE was not always worn correctly
needs fixingMost staff wore PPE correctly, but some did not during the inspection. The manager said this would be investigated.
“We observed most staff wearing PPE correctly in line with current government guidance however some staff were not.” from the report
Cleaning records were incomplete
needs fixingThe home appeared clean, but cleaning records were not always completed. The manager said they would review them.
“The home appeared clean however, records were not always completed.” from the report
Visitor procedure was not followed
needs fixingSystems were in place to reduce infection risks from visitors, but staff did not follow them during the inspection.
“We saw evidence there was systems in place to prevent visitors from spreading infection on entering the premises however this was not followed during the inspection.” from the report
- 01What did you find when you investigated the staff member PPE concerns?
- 02How do you now check that all staff wear PPE correctly?
- 03How are cleaning records checked for completeness?
- 04What reminders or checks were introduced to make sure visitor infection-control procedures are followed?
- 05What were the home's latest full inspection ratings for Effective, Caring, Responsive and Well-led?
This was a targeted inspection triggered by a COVID-19 outbreak, focused on infection prevention and control and staffing pressures; it did not provide ratings for the other four questions. This explanation was written from the published report of 24 February 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, October 2017
Rated Good overall; inspectors found kind, effective care, but safety checks and some medicines records needed improvement.
This was an unannounced inspection. Inspectors spoke with people living at the home, relatives, staff and a visiting health professional. They reviewed care records and other documents, toured the building and observed a mealtime.
The home had improved since the previous inspection in May 2016. Care plans were now personalised and the previous breach about person-centred care had been resolved. People were supported by kind staff, had access to food and healthcare, and could take part in activities and make complaints.
Safety was the weaker area. Some medicines records were incomplete, and maintenance and equipment checks had been recorded as completed when they had not been. The manager checked the equipment during the inspection and said they were investigating what had happened. The home was rated Good overall, with Safe rated Requires Improvement and the other four areas rated Good.
Kind and respectful care
Inspectors saw staff treating people with dignity and respect. Staff knew people well and supported their individual preferences and independence.
“We saw that people received support from kind and compassionate staff who understood their individual needs.” from the report
Improved care planning
Care plans had improved since the previous inspection. They were written with people and relatives and gave staff clear information about individual care.
“We reviewed four people's care plans and saw detailed, personalised plans that identified how people liked to receive their care.” from the report
Enough staff
Inspectors found staffing levels were adequate for the planned care. Call bells were answered promptly.
“We saw there were enough staff to deliver care safely.” from the report
Food and health support
People had choices of food, snacks and drinks, with alternatives available. Their weights and nutritional risks were monitored, and they had access to health professionals.
“People were supported well to maintain sufficient levels of nutrition and hydration by staff who understood how to meet people's individual dietary needs.” from the report
Listening to people
Residents' and relatives' views were gathered through meetings and surveys. Suggestions led to actions, including more outings.
“This demonstrated the service listened to what people wanted and had acted on their wishes.” from the report
Safety checks were falsely recorded
seriousRecords showed some maintenance and premises checks had been marked as completed before they were actually done. This meant inspectors could not initially be sure that equipment was safe, although the manager completed the checks during the inspection.
“Maintenance and premises safety checks had been falsely completed. This meant we could not be sure equipment was safe.” from the report
Some medicines records were incomplete
needs fixingInspectors found missing signatures on one topical medicines record and gaps in recording PEG flow rates. The manager took action and was advised to review current guidance.
“We recommend that the service consider current guidance on recording medicines administration and update their practice accordingly.” from the report
- 01What changes have been made to prevent maintenance and premises safety checks being recorded as completed when they have not been done?
- 02How are medicines administration records checked now, including topical medicines and PEG flow rates?
- 03How often are medicines audits completed, and what happens when an error is found?
- 04How will you make sure care plans continue to be reviewed with residents and relatives?
- 05How are staffing levels adjusted when residents' needs or dependency levels change?
This was an unannounced inspection covering all five areas; the report describes visits on 27 June and 6 July 2017, although its front page lists 29 June and 6 July. This explanation was written from the published report of 3 October 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 Elmwood Care Home
3 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- October 2017Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Good
- July 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 21 March 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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