Updated 15 January 2026
Date of Assessment: 21 January to 19 February 2026. Elm Tree Lodge is a care home providing support to older and younger people primarily living with a range of mental health needs. Not everyone was in receipt of the regulated activity of personal care, so we only spoke to those who received this support. We assessed this service because it had not been assessed for a long time.
There was a breach of the regulations and fundamental standards in relation to good governance at Elm Park Lodge. This placed people at potential risk of harm.
We found a variety of fire safety concerns mostly in the designated smoking room of the home. We asked the registered manager and management team to take action quickly, which they did.
The provider was not auditing the quality of the care provided, they relied on the registered manager to do this. This was not always effective and this approach limited the opportunity for improvements to be made. Consideration was not given to what could be done differently and what needed to change. Such as asking questions about fire safety and questioning certain established ‘institutionalised’ routines which had become normalised. In this respect the provider was not supporting continuous development.
There was a positive attitude amongst the management team who reacted positively to our feedback and were willing to make changes when necessary. Improved auditing and effective provider oversight should enable this service to improve.
Risk assessments were in place to help keep people safe and to promote their mental wellbeing. People received their medicines as prescribed and these were regularly reviewed by health professionals.
People were supported by enough staff who were trained and felt supported by the registered manager.
We have asked the provider for an action plan in response to the concerns found at this assessment.