CQC report explained · a residential care home
What the CQC found at Three 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, including visiting, testing, admissions, protective equipment and outbreak management. They were only somewhat assured about hygiene and the layout of the premises.
- Effective?
- Good
- This question was not inspected as part of this targeted visit.
- Caring?
- Good
- This question was not inspected as part of this targeted visit.
- Responsive?
- Good
- This question was not inspected as part of this targeted visit.
- Well-led?
- Good
- This question was not inspected as part of this targeted visit.
What inspectors found, April 2022
Inspected but not rated; inspectors found that COVID-19 infection controls were mostly safe, but hygiene was not consistent in some areas.
This was a targeted inspection on 18 March 2022 after a recent COVID-19 outbreak. Inspectors looked mainly at infection prevention and control, and asked about staffing pressures.
The outbreak was managed safely. Visiting procedures, testing, protective equipment and staff training were in place. Visitors were kept informed about arrangements and their relative's wellbeing.
Inspectors were assured about most infection controls. They were only somewhat assured about the layout and hygiene of the home because good hygiene was not consistent in some areas. The service was inspected but not rated.
Outbreak management
The recent COVID-19 outbreak was managed in line with government guidance.
“The outbreak was safely managed in line with government guidance.” from the report
Protective equipment and training
Staff had up-to-date infection control guidance, training and a good supply of protective equipment. Inspectors saw it being used and disposed of safely.
“Staff were provided with the most up to date infection prevention and control (IPC) guidance and were trained in IPC including how to safely use and remove personal protective equipment (PPE).” from the report
Family communication
Visitors understood the visiting arrangements and said staff kept them informed during the outbreak.
“Visitors told us they were kept informed about visiting arrangements and that staff had contacted them during the outbreak to keep them informed about the wellbeing of their relative.” from the report
Inconsistent hygiene
needs fixingSome areas of the home did not have consistent good hygiene practices. Inspectors signposted the provider to resources to improve its approach.
“Good hygiene practices were not consistent in some areas of the home.” from the report
- 01Which areas of the home had inconsistent hygiene during the inspection, and what action has been taken since?
- 02How do you check that cleaning and hygiene remain consistent throughout the home?
- 03How would you keep families informed if there were another COVID-19 outbreak?
- 04How often are residents and staff tested during an outbreak, and how are the records checked?
- 05What staffing measures would be used if COVID-19 caused staff pressures?
This was a targeted inspection of infection prevention and control, with questions about staffing pressures; it did not provide ratings for the other four questions. This explanation was written from the published report of 15 April 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, February 2021
Inspected but not rated; inspectors found good infection control and safe visiting arrangements.
The CQC carried out an announced, targeted inspection on 3 December 2020. It followed concerns about infection prevention and control during the coronavirus pandemic.
Inspectors found safe arrangements for visitors and new admissions. Staff followed shielding, social distancing and personal protective equipment guidance. The home also supported residents to keep in touch with family and friends using technology.
The inspectors were assured that infection risks were being managed, including testing, cleaning, hygiene, outbreak planning and the use of protective equipment. The home was inspected but not rated, so this report does not give an overall quality rating.
Safe visiting
The home had a specific visiting area and procedures intended to reduce the spread of infection while keeping families in contact.
“The service followed safe visiting procedures to minimise the spread of infection.” from the report
Protective equipment
There was a good supply of suitable protective equipment, and staff used and disposed of it correctly.
“There was a good stock of the right standard of PPE and staff used and disposed of it correctly.” from the report
Safe admissions
People newly admitted to the home were given extra support to protect their health and wellbeing.
“Safe procedures were in place for admitting people into the service.” from the report
Infection control systems
Inspectors found current infection control guidance, updates and good practice being shared with staff.
“The registered manager and provider shared infection prevention and control (IPC) guidance, updates and good practice across the staff team.” from the report
Inspectors raised no specific concerns in this report.
- 01How are family visits arranged now, and what infection control measures are currently used?
- 02How are people safely admitted to the home, including any extra support during their first days?
- 03How do you check that staff are using and disposing of protective equipment correctly?
- 04How do you manage and communicate any infection outbreak?
- 05When was the home last assessed on care that this targeted inspection did not cover, such as caring, responsive and well-led care?
This was a targeted inspection of infection prevention and control measures during the coronavirus pandemic; it did not assess the other areas of care. This explanation was written from the published report of 17 February 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 Three Elms
3 rated inspections over 5 years: the service has held its Good rating throughout.
- April 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- February 2021Inspected but not ratedSafe: Inspected but not rated
- November 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- February 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 7 December 2010.
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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