CQC report explained · a nursing home
What the CQC found at Elmwood House Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that infection risks, visiting, admissions, testing, personal protective equipment and outbreaks were being managed. They also found the infection prevention and control policy was up to date.
- Effective?
- Good
- This question was not assessed in this targeted inspection.
- Caring?
- Good
- This question was not assessed in this targeted inspection.
- Responsive?
- Good
- This question was not assessed in this targeted inspection.
- Well-led?
- Good
- This question was not assessed in this targeted inspection.
What inspectors found, February 2022
Inspected but not rated; inspectors found COVID-19 infection controls and visiting arrangements in place.
This was an announced, targeted inspection on 20 January 2022. The inspectors looked at infection prevention and control, visiting arrangements and whether COVID-19 staffing pressures affected care.
The inspectors were assured that the home was using personal protective equipment safely, arranging testing, following distancing and shielding rules, and managing visitors and admissions safely. They also found that the infection control policy was up to date.
The home had checks for staff and visitors, hand sanitiser and protective equipment points, and records of vaccination status and test results. The service was inspected but not rated, so this report does not give an overall quality rating.
Infection control
The home followed COVID-19 guidance and had checks, hand sanitiser and protective equipment available for staff and visitors.
“Elmwood House Nursing Home ensured current government guidelines in relation to COVID-19 were being followed by staff and visitors to reduce the risk of infection to people living at the home.” from the report
Vaccination and testing records
The home kept structured records of vaccination status and test results. The report also says all staff had been vaccinated against COVID-19.
“The Registered Manager had a methodical and structured approach to recording individuals COVID-19 vaccination status and test results.” from the report
Visiting arrangements
Visitors were asked to plan visits ahead and were kept apart from residents to reduce the risk of infection spreading.
“Visitors were kept distanced from other residents to reduce the risk of cross contamination.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection prevention and control arrangements are in place now, and how do they compare with those seen in January 2022?
- 02How are visitors currently checked, tested or managed when they arrive?
- 03How would visits be arranged if there were an infection outbreak?
- 04How are staffing pressures monitored, and what action is taken if COVID-19 affects staffing?
- 05When was the service last assessed for caring, effective, responsive and well-led care?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19 staffing pressures; the service was inspected but not rated and the other questions were not assessed. This explanation was written from the published report of 5 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, April 2020
Rated Good; inspectors found kind, effective care, but staffing levels, activities and leadership were not always settled.
Inspectors visited without notice on 10 and 11 March 2020. They spoke with people living in the home, relatives and staff. They also checked care plans, medicines records, recruitment files, training information and quality records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People generally felt safe and well treated. Their care, food, health needs, medicines and end of life wishes were supported.
There were some areas to watch. People, relatives and staff said there were sometimes not enough staff and people had to wait. Some staff interactions were task-focused, activities were not always available, and there was uncertainty because a temporary manager was in place. The provider had identified shortfalls and action plans were being worked on.
The previous inspection rated the service Requires Improvement and found a breach relating to governance. This inspection found enough improvement for the breach to be removed and all ratings to improve to Good or remain Good.
People felt safe
People and relatives said they felt safe. Staff had safeguarding training and knew how to raise concerns.
“People and their relatives told us they felt the service was safe.” from the report
Personalised care
Care plans recorded people's needs, preferences and what they could do for themselves. Staff supported people to keep their independence where possible.
“People had personalised care plans in place which detailed the support they required and what they were able to do for themselves.” from the report
Food and health support
People were offered choices of food and drinks, including suitable modified diets. Staff worked with health professionals and supported access to dental care.
“People told us they were able to choose what they wanted to eat.” from the report
Respect and dignity
Inspectors saw staff protect people's privacy and offer choices. People and relatives spoke positively about how they were treated.
“We observed staff consider people's dignity when they were in their personal rooms by knocking on their door and waiting for consent for them to enter.” from the report
Improved oversight
The provider had introduced quality checks and action plans. The previous governance breach was no longer in place at this inspection.
“There was an effective quality assurance system in place to assess and monitor quality of the service.” from the report
Staffing and waiting times
needs fixingPeople, relatives and staff said there were sometimes not enough staff and people had to wait for support. A new rota had recently been introduced to address this.
“People, staff and relatives told us they felt there weren't enough staff and there were occasions where people had to wait for support.” from the report
Meaningful interaction
needs fixingSome staff interacted positively, but others were task-focused and did not always offer meaningful interaction. Managers said they would address this through a staff meeting.
“Whilst some staff interacted with people positively, others lacked meaningful interaction and were task focussed.” from the report
Activities were not always available
minorPeople enjoyed the activities, but people and relatives felt there could be too few activities at times. The provider planned for staff from all departments to offer meaningful activities.
“However, people and relatives felt there could be a lack of activities at times.” from the report
Medicines checks found shortfalls
needs fixingAudits identified problems with ordering stock, storing some prescribed items and stock cycles. An action plan was in place and changes had started.
“Medicine audits which had been carried out by the manager had identified shortfalls relating to ordering stock, storing some prescribed items and stock cycles.” from the report
- 01How many care staff and nurses are planned for each shift, and how often are shifts short of staff?
- 02What has changed since the new rota was introduced, and how do you check whether people are still waiting for support?
- 03When will the permanent manager be appointed and registered, and how are staff being kept informed during the transition?
- 04What activities are available every day, including for people who cannot join group activities?
- 05What actions were taken after the medicines audit found problems with ordering, storage and stock cycles?
This was an unannounced inspection of all five key questions, including the premises and the care provided, with checks of records, staff, people and relatives. This explanation was written from the published report of 4 April 2020 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 House Nursing Home
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- April 2020Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2019Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2017
Registered with the Care Quality Commission on 25 August 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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9 live-in carers within about an hour of Lincolnshire
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.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
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.