What the CQC found at Elpha Lodge Residential Care Home

People's communication needs were recorded and staff knew how to support people to express their views. Accessible information and advocacy were available where needed.

“Information was available in accessible formats. For example, easy read documents had been produced using pictures to support people who could not understand written words.” from the report

The home had systems to support visits and contact with relatives and friends, including by telephone and other technology.

“Systems were in place to support people to maintain relationships with their relatives and friends.” from the report

One person described staff as helpful, friendly and polite. Inspectors also recorded positive feedback from a health professional about staff attention to people's needs.

“Ask the staff anything or ask the staff to help you and they'll do it straight away. They are nice friendly and polite.” from the report

Safeguarding referrals had not always been made after allegations of abuse. Inspectors were not assured that the management team understood its safeguarding responsibilities.

“Safe systems were not in place to protect people from harm. We were not assured the management team understood their responsibilities in relation to safeguarding people.” from the report

Some risk assessments were missing. Medicines records and administration were not always accurate, including checks for controlled medicines and instructions for applying creams.

“Medicines were not always managed safely. For example, body map documentation was not in place to guide staff on where topical medicines [creams and lotions applied to the skin] needed to be applied.” from the report

There were not always enough staff to meet people's needs. Recruitment checks were incomplete, and agency staff did not always provide consistent care.

“There was not always enough staff available to safely meet people's needs. A recognised dependency tool was not used to determine how many staff were required which reflected the needs of people.” from the report

Mental capacity assessments were not always completed. Some restrictions were used without the appropriate legal authority, so people's rights were not always protected.

“Processes were not always followed correctly to ensure people's rights were upheld and decisions were made in the best interests of people who lacked the mental capacity to make specific decisions themselves.” from the report

Care plans were not always updated, and some routines fitted staff needs rather than people's choices. Records did not show regular meaningful activities for everyone.

“Person-centred care and support was not always delivered to people. For example, we received feedback from staff that the routine of the home was to start getting people ready for bed at 6pm.” from the report

The provider's audits were not completed consistently and did not identify the problems found by inspectors. Records were disorganised and there had been several management changes.

“The provider did not operate an effective governance system. For example, audits had not always been completed at the timescales identified by the provider to properly monitor the safety and quality of the service.” from the report