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Elmwood Residential Home Limited Good

Inspection Summary

Overall summary & rating


Updated 3 November 2018

This unannounced comprehensive inspection took place on 24 and 25 September 2018. The inspection was to follow up whether improvements had been made from the previous inspection in September 2017.

Elmwood residential home is registered to provide accommodation with personal care for up to 38 people with physical disabilities, long term medical conditions or memory loss. 37 people lived there when we visited.

At the previous inspection on the 13 and 14 September 2017, the service was rated as requires improvement overall, with the safe, effective, responsive and well led domains rated requires improvement and the caring domain rated as good. Four breaches of regulations were found in safe care and treatment, safeguarding, quality monitoring and in relation to a failure to notify the commission about an allegation of abuse. Following the inspection, CQC took further enforcement action by imposing a condition on the provider’s registration. This was because the service had been rated requires improvement with breaches of regulations for the fourth successive inspection. The condition required the provider to provide CQC with a monthly report to demonstrate they were making the required improvements at the service.

CQC met with the provider on 10 January 2018. The purpose of the meeting was to ensure the provider was clear that CQC's expected improvement at the next inspection, with no breaches of regulations. We also emphasised the need to ensure these improvements were sustained. Since December 2017, the service has sent monthly reports, which have included examples of continuous improvements.

Since then, the service has worked closely with the local authority, their quality assurance improvement team and the Care Quality Commission to make the required improvements. The local authority quality assurance and improvement team has visited the service regularly to support the provider to continuously improve their quality monitoring systems. Joint meetings were held with the provider, local authority and care manager to monitor progress and ensure continuous improvements were made. At this inspection, significant improvements had been made in the provider’s quality monitoring systems. People's care records had improved, care plans, risk assessments and daily records were more detailed, and personalised. However, further improvements were still needed to make sure staff had the training and sufficient equipment to use electronic care records effectively.

The provider, registered manager and deputy manager, worked well together. People, relatives, staff and professionals gave us positive feedback about the quality of people’s care. They spoke about improvements in communication, professional development and improved quality monitoring systems.

The service has a 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.

People were protected from abuse because the leadership team had completed additional safeguarding training with the local authority. They demonstrated a good understanding of their responsibilities to report safeguarding concerns, and worked in partnership with other agencies, where concerns about abuse were identified. The service informed the local authority safeguarding team about suspected abuse and notified the Care Quality Commission (CQC). Where concerns about staff practice were identified, they were robustly dealt with through additional training, supervision, and if needed, by following the provider’s disciplinary procedures.

Staff demonstrated a good awareness of each person's safety and how to minimise risks for them. Improvements had been made in the garden to improve people’s access and redu

Inspection areas



Updated 3 November 2018

The service was safe.

People were protected from abuse, because safeguarding systems had improved. Staff knew about their responsibilities to safeguard people and how to report suspected abuse. Any concerns were appropriately responded to.

People were protected from avoidable harm because internal and external improvements made had minimised risks. Risks for people were assessed and actions taken to reduce them.

People reported feeling safe living at the service, which had enough staff to meet their needs.

People received their medicines in a safe way.

People were protected from cross infection by good hygiene and infection control measures.

A robust recruitment process was in place to ensure people were cared for by suitable staff.



Updated 3 November 2018

The service was effective.

Improvements had been made in meeting the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Where people lacked capacity, best interest decisions had been made, which minimised restrictions on people�s freedom.

People were well cared for by staff who had regular training to gain the knowledge and skills to support people�s care and treatment needs.

People were supported to access healthcare services. Staff recognised changes in people's health, sought professional advice appropriately and followed that advice.

People were positive about the choices and quality of food. Staff supported people to improve their health through good practice in nutrition and hydration.



Updated 3 November 2018

The service was caring.

Most people and relatives said staff were caring and compassionate and treated them with dignity and respect. Where any concerns were identified, they were robustly dealt with by the provider.

Staff knew people well and developed positive relationships with them.

People were able to express their views and were involved in decision making.


Requires improvement

Updated 3 November 2018

Some aspects of responsive needed further improvement.

People's care records had improved. They were more personalised, detailed, up to date and securely stored. Further improvements were needed to ensure care staff had the equipment and training to use electronic care records effectively.

People received care which met their individual needs. Improvements had been made to make activities more personalised.

People knew how to raise concerns and complaints which were positively and robustly responded to.

People who received end of life care at the service were kept comfortable and pain free.



Updated 3 November 2018

The service was well led.

The quality of people�s care had improved because the service had made significant improvements in quality monitoring systems.

The leadership team were proactively monitoring and reducing risks, and continuously improving care and the environment through audits, and in response to feedback.

People, staff and visiting professionals expressed confidence in the registered manager and deputy manager. The culture was more open, with improved partnership working with external agencies.

The provider set clear expectations for staff about their performance. Senior care staff were being developed to take on more responsibilities, with further development planned.

People, relatives' and staff views were sought and taken into account in how the service was run.