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.
What inspectors found, May 2023
Rated Requires Improvement; inspectors found gaps in risk management, medicines records and checks on the quality of care at The Elms.
This was an unannounced inspection over three days. Inspectors spoke with people, relatives, staff and a healthcare professional. They observed care and reviewed care, medicines, training, recruitment, cleaning and management records.
The home was rated Requires Improvement for Safe and Well-led. Risk assessments were not always kept up to date, fire safety checks did not cover everything needed, and medicines records did not always show that medicines had been given as prescribed.
Inspectors also found that the provider's checks had not identified these problems. There were positive findings too. People described staff as kind and respectful, and inspectors saw person-centred care, suitable infection control and enough staff on duty during the inspection.
The last rating was Good, published on 9 May 2022. This inspection began as a targeted check after concerns about staffing, moving and handling, medicines and visiting. It became a focused inspection of Safe and Well-led when further concerns were found.
Kind and respectful care
People and relatives said staff treated people kindly and respectfully. Inspectors also observed staff supporting people in a calm and helpful way.
“People told us they were always treated with kindness and had never been treated badly.” from the report
Person-centred support
Staff knew people well and responded to individual needs, including for people living with dementia. They supported independence while helping when needed.
“There was a person-centred approach to the delivery of people's care.” from the report
Staffing and recruitment
Recruitment had improved and the home was almost fully staffed at the inspection. Inspectors observed enough staff on duty to meet people's needs.
“At the time of the inspection staff recruitment had improved and the service was almost fully staffed.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing infections, including using protective equipment safely.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Risk assessments were out of date
seriousSome assessments and plans for falls, choking, pressure ulcers, seizures and moving and handling had not been reviewed regularly. This meant staff and visiting professionals might not have had the latest information.
“Risk assessments and associated plans for managing people's health risks had not been maintained and reviewed regularly.” from the report
Medicines records were not reliable
seriousStock counts, administration records and signatures did not always match. Some medicines were recorded as unavailable when they were in stock, and pain relief patches were not always used according to the manufacturer's instructions.
“We were not fully assured that people had always received their medicines as prescribed.” from the report
Fire safety monitoring had gaps
seriousSafety monitoring did not fully ensure that staff knew how to support people during a fire. Fire evacuation training and extra door checks were arranged during the inspection.
“Safety monitoring processes had not been sufficiently scoped to ensure staff knew how to safely support people in the event of a fire.” from the report
Provider checks had not found problems
seriousThe provider's own quality monitoring had not identified the shortfalls in risk management, fire safety and medicines. The service improvement plan and audits were amended during the inspection.
“During the inspection we identified shortfalls which the provider had not identified through their own monitoring processes.” from the report
- 01How have you updated and reviewed each person's risk assessments, especially for falls, choking, pressure ulcers, seizures and moving and handling?
- 02What checks now confirm that medicines are given as prescribed and that administration records, signatures and stock counts match?
- 03What fire evacuation training has all staff completed, and how do you support each person to leave safely?
- 04How often are your audits reviewed, and how do they now identify problems before they affect people's safety?
- 05What progress has been made on the action plan requested after this inspection?
This was a focused inspection of Safe and Well-led, following targeted concerns; the other key question ratings carried over from the previous inspection. This explanation was written from the published report of 23 May 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.
What inspectors found, May 2022
The Elms was rated Good; inspectors found safe, well-managed care, with recent staffing recruitment challenges.
This was an unannounced focused inspection. Two inspectors visited on 13 April 2022 and spoke with relatives by telephone on 14 April. They spoke with people, relatives, staff and a healthcare professional, and checked care, medicines, recruitment and management records.
Inspectors found people felt safe and well looked after. Risks such as falls, pressure ulcers, poor nutrition, infections and the use of equipment were assessed and reviewed. Medicines were managed safely, and staff knew how to recognise and report abuse.
The home was also judged well-led. People, relatives and staff said communication was good and managers were approachable. The overall rating was Good, and the Safe and Well-led ratings remained Good.
Risks were managed
People's health and care risks were assessed and reviewed. The home had processes for managing falls, pressure ulcers, nutrition, infections and behaviours linked with dementia.
“People's risks were reviewed on a regular basis, to ensure the action taken to reduce these remained appropriate and effective.” from the report
Medicines were safe
Staff were trained and checked when supporting people with medicines. Medicines were available when needed, stored correctly and regularly audited.
“Regular stock checks, medicine audits and reviews by the attending GP ensured people received the medicines they required, and which had been prescribed for them.” from the report
Open management
People, relatives and staff felt able to speak with managers and raise concerns. Inspectors found systems for monitoring quality and making improvements.
“There were effective systems in place to monitor the quality of care provided, to identify and manage risks such as falls and the development of pressure ulcers and, to drive necessary improvement.” from the report
People's views were heard
The home sought feedback from people and relatives, including from people living with dementia. Suggestions from residents were acted on.
“Adapted questionnaires had been used to support people who lived with dementia to be included in this process.” from the report
Recruitment had been difficult
minorThe service had faced challenges recruiting suitable staff. Inspectors said staff working as a team had enabled people's needs, cleaning and laundry to be managed, and new staff were due to start.
“The service had experienced challenges in recruiting suitable staff, however, new staff were due to start soon, and these challenges had been overcome by staff working as one team.” from the report
- 01Have the new staff mentioned in the report started, and how many suitable staff are now in place?
- 02How do you currently monitor and respond to falls, pressure ulcers and changes in people's skin?
- 03How are medicines checked, including medicines needed between the home's monthly orders?
- 04What visiting arrangements are in place now following the recent COVID-19 outbreak?
- 05How can residents and relatives give feedback, and what recent changes have been made as a result?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection when calculating the overall rating. This explanation was written from the published report of 10 May 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.
Every inspection of The Elms
6 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- May 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2022GoodSafe: GoodWell-led: Good
- November 2020Inspected but not ratedSafe: Inspected but not rated
- December 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- November 2018Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- April 2017Goodstayed GoodSafe: Good
- December 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2019
Registered with the Care Quality Commission on 16 May 2019.
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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