CQC report explained · a nursing home
What the CQC found at Elvaston Lodge Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2022
Inspected but not rated; inspectors were assured that infection control measures were in place during the COVID-19 outbreak.
This was a targeted inspection on 19 January 2022. It looked mainly at infection prevention and control during a COVID-19 outbreak, and also asked about staffing pressures. The visit was announced two hours beforehand.
Inspectors found screening, temperature checks, hand washing facilities and hand gel for visitors. They also found enhanced cleaning, appropriate use of protective equipment, regular COVID-19 testing and an up-to-date infection control policy.
Inspectors said they were assured that the home was managing visits, admissions, social distancing, protective equipment and infection outbreaks safely. The home was inspected but not rated, so this report does not give a Good, Requires improvement or Inadequate rating.
Infection control
The home had enhanced cleaning arrangements, including regular cleaning of frequently touched areas such as handrails and door handles.
“Enhanced cleaning schedules included regular cleaning of touch areas such as handrails and door handles.” from the report
Protective equipment
Staff had training in infection prevention and control and inspectors observed them using protective equipment appropriately.
“Staff were observed wearing PPE appropriately.” from the report
Testing and risk checks
People living in the home and staff had regular COVID-19 testing, with individual risk assessments and protective measures in place.
“People and staff had risk assessments in place to identify their individual risks associated with COVID-19.” from the report
Visiting arrangements
The home used visitor screening and understood the arrangements for essential care givers during lockdown. People were also supported to keep in touch by video and telephone.
“A COVID - 19 screening questionnaire and track and trace details was required for all visitors, to complete upon entry.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you currently managing staffing pressures linked to COVID-19, and what happens if staffing levels fall?
- 02What infection control checks are now carried out for visitors and visiting professionals?
- 03How often are people living in the home and staff tested for COVID-19?
- 04How do you ensure staff use protective equipment correctly and follow the infection control policy?
- 05How are visits arranged now, including visits from essential care givers?
This was a targeted inspection of infection prevention and control, with questions about COVID-19-related staffing pressures; it was not a full assessment of all five CQC questions. This explanation was written from the published report of 29 January 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 2019
Rated Good; inspectors found safe, kind and well-organised care, with some missed opportunities to support conversation, activities and drinks.
This was an unannounced, comprehensive inspection on 13 March 2019. Two inspectors and an expert by experience visited the home. They spoke with people, family members, managers and staff, and checked care plans, staff records, medicines and quality checks.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people felt safe, staff understood their needs, care plans were followed and medicines were managed safely.
The report says improvements had been made since the previous inspection, which was rated Requires improvement. Inspectors still saw some missed chances for staff to engage people in conversation, offer help with drinks and provide activities. They also found that some mental capacity records did not fully explain how decisions had been reached.
People felt safe
People said they felt safe and had confidence in the staff. Risks were reviewed when people's needs changed, with equipment and plans used to reduce harm.
“People told us they felt safe and had confidence in the staff who provided their care.” from the report
Safe medicines care
Medicines were stored securely, records were accurate and stocks were correct. Staff were trained and checked as competent.
“People's medicine was managed safely. Medication administration records were accurately completed and stocks of medicine were correct.” from the report
Kind and respectful care
Inspectors saw staff reassure people who were upset and support their privacy, dignity, choices and relationships.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Personalised support
Care plans included people's individual needs, communication methods, interests and wishes. Families were invited to help review care.
“People's care plans were person centred and contained individualised and specific details to ensure people's care needs were met.” from the report
Improved management
The report says the service had improved since the previous inspection. Managers used audits, feedback and action plans to identify and address shortfalls.
“We found improvements had been made following the previous inspection of Elvaston Lodge by the Care Quality Commission.” from the report
Missed chances to offer drinks
needs fixingInspectors saw that staff did not always respond when people asked for a drink. The manager said staff would be reminded about encouraging fluids.
“However, we saw missed opportunities for staff to respond to people when they asked for a drink.” from the report
Mental capacity records
needs fixingSome records did not show how the decision that a person lacked capacity had been reached. The manager said record keeping would be improved.
“We found records did not provide evidence to support and reflect how the decision that a person did not have capacity had been arrived at.” from the report
Communal room layout
minorThe arrangement of chairs made conversation harder and restricted some people's view of the television. The manager said the layout would be reviewed.
“The layout did not promote people to speak with each other and restricted the view of the television for some, which was on a wall.” from the report
- 01How do you now make sure people receive drinks promptly when they ask for them?
- 02How often do staff spend time talking with people who are sitting alone?
- 03What activities are available each day for people on both floors, including those who prefer to stay in their rooms?
- 04How are mental capacity decisions recorded, including the evidence behind the decision and when it will be reviewed?
- 05What changes have been made to the communal room layout so everyone can see the television and speak with others?
This was an unannounced comprehensive inspection covering all five CQC questions, following a previous Requires improvement rating. This explanation was written from the published report of 10 April 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 Elvaston Lodge Nursing Home
3 rated inspections over 3 years: the service has held its Good rating throughout.
- January 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- April 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- September 2020
Registered with the Care Quality Commission on 17 September 2020.
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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