Elm View Care Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Quality assurance systems were in place, these included audits of a range of areas to be carried out by the home manager and on-site staff. However, these systems were not always effectively operated. We found shortfalls which had not been identified by the audits. Risk assessment audits had failed to identify areas lacking sufficient guidance for staff. We found inconsistencies in some care plan records. Training for staff was in place, however in some areas it was out of date or had not been undertaken . There was a system to support staff. We found supervisions had not taken place. We found concerns around documentation relating to the health, safety and welfare of service users as record keeping was not always accurate, complete and contemporaneous. Other shortcomings we identified, included gaps in capacity assessments and best interest processes. This resulted in a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The home liaised with external professionals when required. There was a management structure in place and staff knew their roles and felt supported by the home manager. People’s documentation we reviewed contained incomplete or inconsistent information which could lead to risks in safe care and treatment being provided. Audits we saw had not identified this. The provider had an overarching improvement plan, and they were working through its completion at the time of the inspection.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The home received regular visits from healthcare professionals to meet people's health needs. The service had a clear management and staffing structure and staff were aware of their roles and responsibilities. However, it was not always clear how senior staff communicated important information effectively with staff as we did not see any team meeting minutes or evidence of how information was shared so all staff remained up to date. The home manager regularly submitted statutory notifications. However, processes at the service did not always promote continuous learning particularly as supervisions with staff had not occurred. Where discussions had taken place there was no recording of staff development needs. However, we did receive evidence of how the home manager would be carrying out staff supervision and ensuring training was completed following us raising concerns at our onsite assessment. Other shortcomings we identified, included gaps in capacity assessments and best interest processes, failure to risk assess in response to people’s needs and gaps in staffing levels and skill mix. Audits had failed to identify when records did not accurately identify peoples nutritional and hydration needs. For example, where records had not identified daily fluid targets or where records of modified diet levels were inconsistently recorded in different places. This could lead to inconsistent levels of care and could put the person at risk. The provider had systems, policies and procedures to support the effective assessment of mental capacity. However, management had not identified where the service was not working in accordance with the associated national guidance. For example, staff had either not completed Mental Capacity Assessments or had signed peoples consent records . This was a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service had quality assurance systems which included regular audits of a range of areas to be carried out by the home manager and on-site staff. However, these systems were not always effectively operated. We observed audits had not always been regularly completed, recorded or reviewed which meant some concerns relating to the care and safety of people may not be identified in a timely way. Some audits were 2 months out of date. The home manager had not completed any staff supervisions since July 2023 and team meetings were not regularly held. Training records were not always accurate and training around choking, epilepsy and diabetes management had not been completed by all care staff. Care plan reviews were not always carried out and information on the system was not always up to date. For example, we found 3 people’s care plans contained inconsistent information regarding the support they required with either managing their modified diet, diabetes or epilepsy. Electronic records did not contain a complete and contemporaneous record in respect of each service user. The electronic notes system was used inconsistently to log contact with people, relatives, and professionals. There was no indication of how and when daily notes had been audited or checked for accurate recording. This meant when reviewing people's records some information was inaccurate. This was a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had an overarching improvement plan, and senior staff were working through it at the time of the assessment. Some of the shortfalls we found at our assessment had already been identified through the provider's quality assurance systems and remained within the target action dates, however other issues we found had not been identified. For example, people’s care records were not always providing consistent information about the support they required which had not been identified during the service’s internal audits.

Staff and leaders told us about the ways in which they were continually looking to improve the service. The manager told us they had initiated a call bell monitoring system to reduce waiting times and delays in people receiving care. Additionally, the regional quality assurance lead explained how they were encouraging relatives to sign up on to the providers platform so they could have immediate access to care records. This would enable them to monitor and contribute to how care should be effectively provided to their relative. Although there were some improvements and innovations, the provider's systems did not always effectively monitor the quality of care provided to drive improvements. The governance systems in place had not always identified risks associated with inconsistent record keeping in the management of people's health conditions. Governance systems in place had failed to identify the lack of detailed enough information in care plans for staff to safely manage some elements of people's care. For example, epilepsy, levels of nutrition and hydration and times when people experienced high levels of emotional expression. Quality assurance systems had not always identified that care plans sometimes contained contradictory information, for example, about the level of modified food or drink required to reduce their risk of choking. The system in place had not always ensured care plans were updated with new information from external health professionals such as speech and language therapist. This meant there was a risk key information to meet people's assessed health needs was not effectively communicated to staff.