We carried out a review of the data available to us about Elmdene on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Elmdene, you can give feedback on this service.
At the last inspection of Elmdene on 25 October 2015, the service was rated Good overall, although, we found that robust checks were not always completed around recruitment of staff. We asked the provider to comply with this requirement. At this inspection we found the service had made the required improvement and their rating remained Good.
There was no registered manager in post. The provider was in the process of registering to become the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Staff employed at the service had undergone thorough checks to ensure they were fit to work with people. Staff and the provider were committed to protecting people from abuse. Staff were trained in safeguarding people from abuse and demonstrated that they understood the signs of abuse and how to report any concerns in line with the provider’s procedures. There were sufficient numbers of staff to support people at the service. Risks were assessed and management plans were developed to mitigate any risks identified. Staff followed risk management plans for people.
People’s needs were assessed with involvement of relevant professionals where required to ensure their needs were met. Support plans focused on meeting people’s individual needs and goals. People were supported to learn new skills, develop their interest, become independent; and move-on to independent living. People were supported to do the things they enjoyed and gain meaningful and paid occupation. Regular reviews took place to ensure support delivered to people continued to meet their needs.
People’s medicines were managed and stored in a safe way. Health and safety of the environment was maintained. Staff followed good infection control procedures. Staff reported incidents. The provider reviewed and took actions to prevent them from happening again. Lessons were shared with staff.
Staff were trained, supervised and had the skills and knowledge to meet people’s needs. People’s nutritional and dietary needs were met. People were encouraged to cook for themselves. Staff worked effectively with health and social care professionals to attain positive outcomes for people. People had access to healthcare services to maintain good health. The service had systems in place to enable smooth transition when people moved between services. There were suitable facilities and adaptations available for people to use.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff understood their responsibility under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. People knew how to make a complaint if they were unhappy with the service. The provider investigated complaints in line with their procedure.
Staff understood people’s needs and treated them with respect, kindness and dignity. Staff supported people to express their views and people were involved in planning their care and support. People were supported to maintain their religious and cultural values.
Staff received the support, direction and leadership they needed. There were systems in place to monitor and assess the quality of service provided. The service worked in partnership with external organisations to develop and improve the service.
This inspection took place on 26 October 2015 and was unannounced. Elmdene care home was registered with the Care Quality Commission on 27 April 2015. This was the first inspection at the home.
Sunrise Mental Health Ltd - Elmdene provides care and support for people with mental health needs. It can accommodate up to five people. Elmdene Road is a large terraced house over three levels with five bedrooms with communal bathrooms, kitchen, dining and living room areas. There is a communal outdoor area with a patio and summer house.
At the time of the inspection the service was providing care and support to four people.
There was a registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People using the service said they felt safe and that staff treated them well. Safeguarding adult’s procedures were robust and staff understood how to safeguard the people they supported from abuse. There was a whistle-blowing procedure available and staff said they would use it if they needed to. The provider had arrangements in place to deal with foreseeable emergencies.
People’s medicines were managed safely and people received their medicines as prescribed by healthcare professionals.
We found that insufficient checks had been completed around recruitment of staff that related to gaps in employment. Staff had received training specific to meet the needs of people using the service. Staff received regular supervision and an annual appraisal of their work performance. The manager and staff demonstrated a clear understanding of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.
People were involved in planning of their care needs. Care plans and risk assessments provided clear information and guidance for staff on how to support people to meet their needs. Staff encouraged people to be as independent as possible. People were supported to have a healthy and balanced diet.
There were regular meetings where people were able to talk about things that were important to them and about the things they wanted to do. They were aware of the complaints procedure and were confident their complaints would be fully investigated and action taken if necessary.
The provider sought the views of people using the service, staff and relatives through surveys. They used feedback from these surveys to make improvements at the home. Health care professionals were also encouraged to give feedback of their experience of the service. The manager recognised the importance of regularly monitoring the quality of the service provided to people. Staff said they enjoyed working at the home and they received good support from the manager.
We found a breach of the legal requirements in relation to staff recruitment. You can see what action we told the provider to take at the back of the full version of the report.