CQC report explained · a residential care home
What the CQC found at St Elmo Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always stored, prescribed or administered safely, and accident and incident records did not always show what action had been taken. Risk assessments, staff recruitment checks, premises checks and infection control were areas of strength.
- Effective?
- Requires improvement
- The home assessed people's needs, provided suitable meals and involved health professionals when needed. However, inspectors were not assured that Mental Capacity Act assessments and best-interest decisions were being completed properly.
- Caring?
- Requires improvement
- People and relatives described staff as kind and respectful, and staff knew people well. Inspectors found concerns about privacy, dignity and how one person's personal space was used.
- Responsive?
- Requires improvement
- Care plans were personalised and reviewed, but activities were limited because there was no activities staff member. Inspectors also found that people were not always supported well during lunchtime or with communication needs.
- Well-led?
- Requires improvement
- The home had regular audits and sought feedback, but audits lacked detail and did not identify important shortfalls. Some significant events were not reported to CQC, and staff team problems were affecting people's wellbeing.
What inspectors found, April 2023
St Elmo Care Home was rated Requires Improvement; inspectors found problems with medicines, incident follow-up, consent, activities and management oversight.
This was an unannounced inspection on 30 January and 6 February 2023. Inspectors spoke with people, relatives and staff, observed care, reviewed care records, recruitment files and management records, and checked infection control.
The home was not always safe. Medicines were not consistently managed properly, and records did not show that accidents and incidents had been fully investigated or that learning was shared with staff. The premises were clean and risks had generally been assessed.
Inspectors also found weaknesses in consent decisions under the Mental Capacity Act, respect for privacy and dignity, activities, communication and lunchtime support. Care plans were person-centred, meals were appetising and staff knew people well.
All five areas were rated Requires Improvement. This means the service was not consistently meeting people's needs and there was limited assurance that care was safe, effective, caring, responsive and well managed. The previous overall rating was Good in 2019.
Risk assessments and checks
People's needs, equipment and the environment had been assessed for risks. Fire, equipment and building checks were completed as scheduled.
“Numerous risk assessments had been completed to ensure safe provision of care.” from the report
Cleanliness and infection control
Inspectors found the premises clean and were assured that infection risks were being managed, including the safe use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Person-centred care plans
Care plans included people's histories, preferences and communication needs. They were reviewed regularly and updated when needed.
“Care plans were person centred and included information on what a good or bad day may look like and historical medical information that may still be relevant.” from the report
Food and healthcare support
People received meals, drinks and snacks, and were referred for specialist swallowing assessments when needed.
“People's nutritional needs were met and appetising meals were provided along with drinks and snacks through the day.” from the report
Kind and familiar staff
People and relatives said staff were caring and respectful. Inspectors also found that staff knew people well.
“The staff are very caring and kind. They are respectful when they are helping me.” from the report
Accidents and incidents
seriousRecords did not always show whether medical advice, treatment or reporting had taken place. Learning from incidents was not shared with staff to help prevent them happening again.
“We were not assured that learning was taken from accidents and incidents to prevent reoccurrence.” from the report
Consent and best-interest decisions
needs fixingThe home did not consistently assess whether people could consent to medicines and other care. Inspectors recommended reviewing the home's procedures under the Mental Capacity Act.
“We were not assured the provider was fully aware of their responsibilities under the MCA.” from the report
Privacy and dignity
needs fixingInspectors were concerned that a person's bedroom was offered as a work space and used to store delivered items. One person was also not supported to put on a coat when going outside.
“We were concerned to be offered a person's bedroom to work in during our inspection.” from the report
Activities and mealtimes
needs fixingThere was no activities staff member, and some care staff were reluctant to lead activities. Inspectors also saw limited interaction during lunch and people were not always supported to communicate or take part socially.
“Some staff were reluctant to run activities meaning people were, at times, not engaged or supported to lead fulfilling lives.” from the report
Management oversight
seriousSome significant events were not reported to CQC. Management audits were not detailed enough to identify problems, and staff team difficulties were affecting people's wellbeing.
“The insufficient oversight of service provision was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, good governance.” from the report
- 01What changes have been made to medicine protocols, storage temperatures and the safe use of prescribed thickeners?
- 02How are accidents, falls and safeguarding incidents now investigated, recorded, reported to CQC and discussed with staff?
- 03How do you assess capacity and record best-interest decisions for medicines and other care?
- 04Who is now responsible for activities, and how do you make sure people are supported during activities and lunchtime?
- 05What new checks show that the management team is identifying and fixing problems?
This was an unannounced inspection covering all five key questions and infection prevention and control; the overall rating changed from Good at the previous inspection to Requires Improvement. This explanation was written from the published report of 4 April 2023 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 St Elmo Care Home
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- April 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2019Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2017GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2021
Registered with the Care Quality Commission on 29 March 2021.
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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