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 – 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 changed to Good. This meant people were safe and protected from avoidable harm.

The service was previously in breach of legal regulation in relation to safe care and treatment. The provider had ensured the service was now being delivered safely and this regulation was complied with.

This service scored 75 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider and registered manager had acted on the concerns raised at the last assessment to improve the safety of the service. Effective governance ensured that any issues or concerns were promptly identified and addressed. A relative told us, “I have visited Elmwood on numerous occasions over the last three years. Over the past 12 months I have been immensely impressed by the changes the new manager has brought about.”

Environmental safety checks and fire safety processes were established, including an improved fire risk assessment and regular fire drills for all staff.

There were now effective systems in place to ensure air pressure mattresses were set correctly and people’s skin integrity supported.

A health and safety advisor had been commissioned to provide additional oversight on a monthly basis.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The registered manager carried out a comprehensive face to face assessment with each person before they moved into Elmwood. Where appropriate, family members were involved to help build a detailed understanding of the person’s background, needs and preferences. A relative told us, “I think the management at Elmwood is excellent and very experienced. From the outset, everything was explained to me very clearly (as this is the first time a member of my family has been in care) and all my questions were answered.”

People had personalised care plans containing clear information about their physical and mental health, communication needs and day to day support requirements. These plans were accessible to relevant healthcare professionals, supporting effective information sharing and improving consistency of care.

External health professionals confirmed the service was proactive in raising any concerns to them and following guidance. The provider had robust systems in place to document all communication with the GP surgery and pharmacy, ensuring records were complete, traceable and available for review when needed.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There were now effective systems in place to ensure air pressure mattresses were set correctly and people’s skin integrity was supported. This mitigated the risk of pressure sore development. There were no pressure sores being treated at Elmwood during our site visit.

Risk assessments were detailed and person centred, promoting the health, safety and welfare of people using the service. People and their relatives were involved in this process. They were reviewed regularly to ensure they were up to date. Staff confirmed, “Care plans are kept up to date and they clearly reflect each resident’s individual needs. They provide useful guidance on how best to support residents, including any risks and the safest way to deliver care.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Following our last assessment the provider had commissioned regular reviews by a health and safety advisor to promote environmental safety. Environmental safety checks had been completed covering areas such as fire safety, gas and electrical installations, water systems and equipment maintenance. The service had personal emergency evacuation plans for each person and considered individual mobility and health needs that might affect how they left the building in an emergency.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Following the last assessment the provider had taken action to improve the safety of recruitment processes. Recruitment files showed they had conducted appropriate recruitment checks before staff started working at the service. This included identity, references, employment history and enhanced criminal record checks to ensure staff were suitable to be working with vulnerable people.

The provider had invested significantly in the training and development of the staff team. All staff, in all roles, had undertaken a 3-day reinduction programme, to refresh knowledge and skills and ensure they could apply their learning to practice. The registered manager continued to build on this with mandatory and more in-depth training covering topics such as dementia and Positive Behavioural Support (PBS). Additional training was provided when necessary to ensure staff were able to meet people’s individual needs. Staff spoke positively about the reinduction and training. Comments included, “I did the 3-day induction. Before it was not organised but now it is all done more efficiently. The induction was good and thorough” and “I have been very impressed with the training I have received at Elmwood. Despite being kitchen based I was given access to the same courses both online and classroom based as the care staff. This has enabled me to better understand everyone else's roles at Elmwood and also the needs of our residents. As a result, I feel far more confident in my role, and I am sure this makes me more capable of meeting the needs of the residents."

Professionals, relatives and people living at Elmwood were confident staff had the knowledge and skills to meet their needs. A relative said they had spoken with several of the nursing staff and was impressed with their level of training and experience.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider had taken decisive action to improve infection prevention and control. A full legionella risk assessment had been undertaken and any recommendations completed.A team of domestic staff maintained the cleanliness of the home, with support and oversight from a dedicated line manager. The service had clear cleaning schedules, and safe systems in the laundry, An IPC (Infection Prevention and Control) champion role had been created to support safe working practices and a positive infection prevention culture.

Staff had infection prevention and control training and could describe how they used this knowledge in practice to minimise infection risks. We saw personal protective equipment was readily available and used appropriately and consistently by staff.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medication administration was well managed. Robust systems were in place to ensure people had their medications safely as prescribed, and that this was recorded correctly. These included medicines requiring additional safety measures, and ‘as required’ medication. The service had a policy of requesting the GP confirm any changes to medication be confirmed in writing, to ensure this was done correctly.

Some people were receiving pain relief through medication patches applied to their skin. The location of these on the person’s body was appropriately rotated and recorded on the electronic medication administration system.

Medicines were stored and disposed of safely. Staff had received appropriate medicines training, and this included ongoing competency checks which were up to date.