CQC report explained · a residential care home
What the CQC found at The Elms
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about most infection prevention and control arrangements. They were only somewhat assured about the layout and hygiene practices of the premises, and found some repairs were still waiting.
- Effective?
- Good
- This question was not assessed in this targeted inspection.
- Caring?
- Outstanding
- 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, March 2022
HF Trust - The Elms was inspected but not rated; infection controls were mostly reassuring, but some repairs and activities were not fully in place.
This was a short, announced inspection on 1 February 2022. Inspectors gave 24 hours' notice, spoke with three staff members and one resident, and looked mainly at infection prevention, visiting arrangements and staffing pressures linked to COVID-19.
The inspectors were assured about visitors, admissions, testing, visits, shielding, social distancing, personal protective equipment and the infection control policy. They were only somewhat assured about the layout and hygiene of the building.
Some communal areas needed repair or maintenance. A shower seat had not been repaired for up to three weeks, and there was a hole in a quiet room wall. Inspectors also found that most activities had stopped during COVID-19 and there was no activities lead or coordinator.
The home was inspected but not rated. This means the report does not give a Good, Requires improvement or Inadequate rating. It was a targeted inspection, not a full review of all aspects of care.
Infection control
Inspectors were assured that the home had arrangements to prevent and manage infections, including testing, visiting and use of protective equipment.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Support with healthcare
Staff worked with a district nursing team to help a resident access a vaccination despite a needle phobia.
“We heard the service had worked with their district nursing (DN) team from a local surgery to help one resident” from the report
Support for staff
The provider had measures to support staff returning after shielding and offered wellbeing and counselling support.
“The provider developed a welcome back to work pack for any staff returning after shielding.” from the report
Repairs and building condition
needs fixingSome communal areas needed repair or maintenance. The shower seat had not been repaired and a wall had a hole, while signs and numbers were missing from parts of the building.
“we found one first floor bathroom shower seat had been awaiting repair for 2.5 - 3 weeks.” from the report
Activities
minorMost activities had stopped during COVID-19. There was no activities lead or coordinator, although key workers held online groups about some activities and practical matters.
“Most of the service's activities had been ceased since Covid-19 so all examples staff gave were from around two years before our inspection.” from the report
- 01Have the shower seat and the hole in the quiet room wall now been repaired?
- 02How are building repairs reported, tracked and checked to make sure they are completed promptly?
- 03What activities are currently available, now that most activities had stopped during COVID-19?
- 04Who is responsible for organising activities, given that there was no activities lead or coordinator?
- 05How does the home keep infection control arrangements up to date and support visits?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19 staffing pressures; it did not assess the other four key questions. This explanation was written from the published report of 3 March 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, May 2018
HF Trust - The Elms was rated Good overall, with Outstanding caring and inspectors finding kind, safe and personalised support.
The inspection took place on 26 February and 5 March 2018. The first day was unannounced. Inspectors spoke with people living in the home, relatives, staff and health professionals. They also checked care records, recruitment files, training, medicines and other records.
The home was rated Good for Safe, Effective, Responsive and Well-led. It was rated Outstanding for Caring. Inspectors found strong relationships between staff and people, with support focused on people's choices, independence and goals.
People were protected from harm, received medicines as prescribed and had enough staff support. Staff were trained and worked with health professionals. Care plans were detailed, although records did not always show how progress towards people's goals was checked.
The home was rated Good overall at the previous inspection in October 2015, and it maintained that rating. A Good rating means inspectors found the service met the required standards in the areas checked, although some improvements were still identified.
Kind and personal care
Staff knew people very well and formed strong, trusting relationships. Support was focused on people's individual wishes and wellbeing.
“We found an extremely caring service. Without exception, people receiving support and their relatives spoke positively about the staff that supported them.” from the report
Building independence
Staff helped people achieve goals in small steps, including employment, community activities and overcoming fears.
“Staff were extremely dedicated in ensuring people were kept happy, occupied and lived fulfilling lives.” from the report
Safe medicines and staffing
People received medicines as prescribed. Inspectors also found enough staff to provide care and support and enable people to take part in their chosen activities.
“People received their medicines as prescribed and appropriate records were kept.” from the report
Good activities and community links
People took part in regular activities, holidays and community projects. Inspectors saw most people leaving the home during the inspection days for activities.
“People had access to a good range of activities and maintained good strong links with the local community.” from the report
People's views included
The home used meetings, reviews and accessible information to involve people in decisions about their care and how the home was run.
“People's views and opinions were very important to the service and were used to improve people's care and support plans.” from the report
Goal progress was not recorded clearly enough
needs fixingPeople had goals, but the records did not clearly show that progress was regularly evaluated. This could make it harder to see whether support was achieving the intended results.
“documentation did not robustly show that progress in achieving these was regularly evaluated.” from the report
Some legal authorisations were still pending
needs fixingTwo people had authorised Deprivation of Liberty Safeguards arrangements, while the others were awaiting assessment. One set of conditions had arrived on the inspection day, so the home had not yet checked that the conditions were met.
“At the time of the inspection two people had an authorised DoLS in place with the others awaiting assessment by the supervisory body.” from the report
Some areas needed redecorating
minorThe home was clean and tidy, but inspectors noted worn décor in a few areas. Plans were in place to update some parts, including hallway carpets.
“The home was clean and tidy, although décor was worn in a few areas.” from the report
- 01How do you now record and review progress towards each person's goals?
- 02What is the current position of any outstanding Deprivation of Liberty Safeguards assessments?
- 03How do you make sure all conditions attached to a Deprivation of Liberty Safeguard are followed?
- 04Have the planned improvements to the worn décor and hallway carpets been completed?
- 05How will my relative be supported to choose activities and maintain family and community links?
This was an inspection of the overall service, including the premises and care, and all five quality areas were assessed; the home maintained its Good overall rating from October 2015. This explanation was written from the published report of 4 May 2018 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 The Elms
2 rated inspections over 2 years: the service has held its Good rating throughout.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- May 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- October 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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