Elmwood Residential Home Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Requires Improvement. At this assessment the rating has remained Requires Improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety. They did not always listen to concerns about safety and did not act upon them to make improvements. Lessons were not learnt to continually identify and embed good practice.

Concerns raised at our last assessment about fire safety, mattress settings for people at risk of skin integrity breaking down, and governance had not been fully addressed or learned from. The service had a new manager since January 2025 who had identified some issues and had started to share learning. We fed back to the provider further work was needed by the provider to support the new manager in identifying and embedding good practice.

The manager worked well with people and healthcare partners to establish safe systems of care, but these were not always maintained. They did not always manage or monitor people’s safety. There was continuity of care when people moved between different services. Summaries of people’s needs were available for first responders if people had to be admitted to hospital unexpectedly. People were supported to stay with the same local GP if they wished to when they moved into the service.However, care planning and risk assessment processes to maintain and monitor safe systems of care were not sufficient and not all care plans and risk assessments were up to date.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve this. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The manager shared concerns quickly and appropriately with the local authorities.

Safeguarding concerns were escalated and referred onto the local authority when needed. People told us they felt safe in the service. Staff had completed training in safeguarding.

The provider did not always work well with people to understand and manage risks. Systems to manage risk were not always effective. Staff did not always provide care to meet people’s needs that was safe and in line with agreed plans of care.

On inspection, we found systems were not in place to robustly monitor mattress settings for people at risk of skin integrity breaking down. For example, issues with pressure-relieving mattresses, including incorrect data recording and settings not aligned with the individual’s needs, put people at risk of skin integrity breakdown. After the inspection the service introduced a new policy and skin integrity audit.

Staff told us they encouraged people to make their own choices, and they respected their decisions. One staff member said, "We help people to make their own choices, such as what they want to eat and drink.” However, we saw evidence that some people struggled to understand food names, with one person telling us “We would like clearer communication or visual menus”. There was no evidence this had caused harm to people at the time, however clear communication tools are paramount to keep people safe.

The provider did not always detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care. On inspection, we found a fire evacuation chair which was out of date, and other fire safety equipment which required a service. People were placed at risk of harm in the event of a fire because fire evacuation protocols had not been updated after an escape route was blocked with scaffolding.

During the inspection, scaffolding was found erected within the stairwell. The only visible safety precautions at the time were a sign affixed to the entrance door and a strip of plastic tape at head height—both of which provided limited deterrent value. Notably, construction activity had begun on 12 May 2025, yet a formal risk assessment for the scaffolding was not carried out until 14 May 2025, and only in response to a request from inspectors.

Several staff members had been working in the service for up to 10 months without participating in a fire drill. Although annual training for fire drills, evacuation procedures, and related protocols was planned, new staff, who started after July 2024, had not yet taken part in any drills.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. However, staff worked together well to provide care to meet people’s individual needs.

Training records showed there were gaps in staff training linked to people’s needs. Staff had completed the care certificate, standard 9 of the care certificate covers 'Awareness of mental health, dementia and learning disability. However this was not in depth training to support staff to meet the needs of those people living with a dementia, the training matrix reflected some gaps in training. Staff reported a lack of regular supervision throughout the year. However, they expressed confidence this would improve under the new manager. The manager confirmed a comprehensive supervision and appraisal matrix was being introduced to ensure consistency and accountability moving forward.

Despite concerns, people also shared what they appreciated about the home, 'I like that I can have juice or even wine with my meal'. A variety of drink options were offered, catering to individual preferences.

Recruitment processes were found to be generally sufficient. However, feedback was given to the provider regarding staff-related risks which required proper assessment and mitigation. Specifically, the provider did not consistently carry out necessary risk assessments when needed. In one instance, personal risks highlighted in a letter dated 7 June 2023 were not appropriately addressed, as the recommended actions were not implemented.

People and staff told us there were enough staff to meet people’s needs. The manager used a dependency tool to assess how many staff they needed, based on people’s needs. We observed staff were visible and available throughout our site visits.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of infection spreading or share concerns with appropriate agencies promptly.

Risks associated with Legionella were not always mitigated, because unused water outlets were not always tested as required.

The manager could not always evidence cleaning was taking place. For example, inspectors identified several issues, including missing entries in daily cleaning records; incomplete deep cleaning audits for March and April 2025; undated cleaning rotas; and failure to flush water outlets in infrequently used rooms in line with required protocols.

However, people did not feedback any concerns about the cleanliness of the home, and there was no malodour. We observed staff using personal protection equipment (PPE) such as gloves and aprons, and contaminated items were disposed of appropriately.

Relatives shared positive experiences about the care their loved ones received. One family member praised the hygiene standards at the service, noting staff consistently maintained cleanliness and personal care. They highlighted the person received gentle support with daily tasks such as nail trimming, hair care, and safe movement. Fresh bedding and nightwear were provided every day, with the environment always kept clean.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Risks associated with medicines requiring additional safety measures were not safely managed.

We observed controlled drugs were not always administered and recorded by staff in line with the service medicine policy. People were not always supported to manage their pain effectively. For example, we observed communication difficulties between staff and one person, and they were left with no pain relief.

Medicines were stored and disposed of safely. Staff received training in administering medicines and received competency checks.