CQC report explained · a residential care home
What the CQC found at Elwis House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough suitably trained staff, appropriate risk assessments, safe medicine systems and effective infection control. Staff understood how to recognise and report abuse and how to respond to incidents.
- Effective?
- Good
- Care plans reflected people's needs, choices and goals. Staff received induction, training and supervision, and people were supported with food, healthcare, communication and decision-making.
- Caring?
- Good
- The report did not give a separate rating for Caring. It said people received kind and compassionate care and that staff protected their privacy and dignity.
- Responsive?
- Good
- People were supported to choose activities, maintain relationships, take holidays and work towards personal goals. Communication plans were tailored to individual needs and people could raise complaints.
- Well-led?
- Good
- Inspectors found effective checks and audits, a positive culture and improved partnership working with health and social care professionals. People, relatives and staff were involved in improving the home.
What inspectors found, July 2022
Rated Good; inspectors found safe, kind and person-centred care, with improvements since the service was previously rated Requires Improvement.
The inspection took place on 8 and 13 June 2022. One inspector spoke with people living at the home, relatives, staff and professionals. They reviewed care and medicine records, staff recruitment and training files, building checks and quality records.
The home was rated Good overall. Safe, Effective, Responsive and Well-led were all rated Good. The report did not give a separate rating for Caring. Inspectors found that people were treated with kindness, supported to make choices and helped to pursue activities, relationships and personal goals.
The home had improved since the previous full inspection in December 2020, when it was rated Requires Improvement. A later targeted inspection was not rated. Inspectors said earlier problems with activities, partnership working and medicines management had been addressed.
Choice and independence
Staff focused on what people could do and supported them to make choices, take control of their lives and work towards their goals.
“Staff supported people to have the maximum possible choice, control and independence and they had control over their own lives.” from the report
Safe medicines
Medicine records reviewed were complete. Staff were trained and assessed as competent, and the home had clear guidance for medicines given when needed.
“Samples of medicine administration records (MARs) we reviewed had been completed correctly and there were processes in place to ensure medicines were being stored at the correct temperature.” from the report
Personalised support
Care plans included people's strengths, needs, communication preferences, sensory needs and aspirations. People and relatives were involved in reviewing them.
“People had care and support plans that were personalised, strengths-based and reflected their needs and aspirations, including physical and mental health needs.” from the report
Health support
The home worked with health professionals and supported people with health checks, hospital information, dental care and specialist dietary needs.
“Staff supported people to access appropriate healthcare services when needed. People were supported to attend and take part in annual health checks.” from the report
Improved leadership
The manager had introduced quality checks, worked with other professionals and created a culture focused on people's rights, individuality and outcomes.
“Governance processes were effective and helped to hold staff to account, keep people safe, protect people's rights and provide good quality care and support.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you review whether activities and social opportunities still match my relative's interests and goals?
- 02How will you keep my relative's communication plan up to date, including any advice from speech and language therapists?
- 03If my relative needs specialist feeding or dietary support, how are staff trained and how is professional guidance followed?
- 04What quality checks do you carry out now, and how will you tell families if a shortfall is found?
- 05How are relatives involved in care plan reviews, house meetings and decisions about changes to the home?
This inspection looked at the overall quality and safety of the home, including infection prevention and control; Safe, Effective, Responsive and Well-led were rated, while no separate Caring rating was given. This explanation was written from the published report of 9 July 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, August 2021
Inspected but not rated; inspectors found improved risk controls and infection procedures, but weekly staff testing records were incomplete.
This was a targeted follow-up inspection on 29 June 2021. It checked whether the home had acted on a Warning Notice about safe care and treatment. The inspector spoke with two staff members and checked two people's care plans and risk assessments, along with infection control and audit records.
The home had improved how it managed the risk of a vulnerable person leaving unattended. Extra safety measures were in place and staff discussed the risks regularly. Other risks, including eating and drinking, moving and handling, and pressure injuries, were also assessed.
The home was clean and hygienic. Staff were using protective equipment correctly and visitors were being managed safely. However, records showed that full-time staff did not always receive a weekly PCR test, so the provider was asked to review its testing schedule.
This was not a full inspection and the service was not given a new rating. The Safe question remained recorded as Requires Improvement from the previous inspection, while this targeted inspection was marked Inspected but not rated. The previous overall rating was Requires Improvement.
Improved risk management
The home added safety measures to reduce the risk of a vulnerable person leaving unattended. Staff discussed the risks and senior managers checked whether the measures were working.
“Enough improvement had been made at this inspection and the provider was no longer in breach of this part of regulation 12.” from the report
Clearer risk assessments
Risks linked to eating and drinking, moving and handling, and pressure injuries were assessed. The assessments gave staff clear instructions on keeping people safe.
“Risk assessments contained clear guidance for staff to ensure they understood how to keep people safe.” from the report
Clean and hygienic home
Inspectors found the home clean and hygienic. Staff followed cleaning schedules and received regularly refreshed infection control training.
“Staff followed cleaning schedules to ensure levels of cleanliness were maintained and the service was clean and hygienic when we visited.” from the report
Better use of protective equipment
Inspectors saw staff using protective equipment correctly. Visitors were asked to test, use PPE and follow hand hygiene procedures.
“The manager had discussed the use of PPE during staff meetings and we observed staff to be wearing PPE appropriately during this inspection.” from the report
Weekly testing records
needs fixingRecords showed that full-time staff did not always receive a weekly PCR test because of changing shift patterns. The provider was asked to review the testing schedule.
“This meant full time staff did not always receive a weekly PCR test.” from the report
- 01What changes have you made to ensure every full-time staff member receives the required weekly PCR test?
- 02How do you now check that the extra security gate and other measures continue to prevent someone leaving unattended?
- 03How often are people's risk assessments for eating and drinking, moving and handling, and pressure injuries reviewed?
- 04How do you check that staff follow each person's risk management plan?
- 05What is the current overall rating following the next full inspection?
This was a targeted inspection of specific Safe concerns linked to a Warning Notice; it did not assess all five key questions and did not change the previous ratings. This explanation was written from the published report of 4 August 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.
Every inspection of Elwis House
5 rated inspections over 7 years: the service has held its Good rating throughout.
- July 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2021Inspected but not ratedSafe: Inspected but not rated
- December 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2019Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- January 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2014Inspected but not rated
- June 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 26 January 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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