Elm Park Lodge

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 good. At this assessment the rating has changed to 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.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was not always a learning culture amongst the staff and managers.

There were systems in place to review incidents to look for lessons learnt for next time. Staff were briefed about incidents and the associated risks by the registered manager. The registered manager and management team took actions when we raised issues and demonstrated to us their willingness to learn. But this learning culture was hampered because of limited and at times ineffective auditing into the quality of the care provided.

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

The registered manager liaised with social workers and mental health professionals to manage the risks people could experience. There was an incident reporting process which led to reviews of the risks which some people faced. As a result of this monitoring of risk the registered manager made the considered decision when the ‘service’ could no longer meet some people’s needs. When this happened, plans were made to support people to move on in a safe way.

The provider and registered manager did not always work well with staff to promote people’s rights to live in safety, free from abuse, and neglect.

Care staff were trained in how to safeguard people from potential abuse. They knew they must report their concerns quickly. However, 2 staff who were not carers, but who worked in the home had not had this training despite being at the home some months and their work bringing them into daily contact with people. By not providing this training the provider put people at potential risk of harm. The registered manager scheduled this training as a result of this feedback.

The provider did not always work well with people to understand and manage risks.

The registered manager had assessed people’s needs and involved people as much as possible in relation to certain key risks which people faced. However, some risks were not identified and set out in care plans to guide staff practice. For example, people had access to boiling water taps about the home to make a hot drink, this was not risk assessed. A person’s behaviour could potentially pose a risk to others; this was not explored in a risk assessment. This placed people at potential risk of harm.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider had commissioned a fire specialist company to assess the fire safety of the building. Various fire safety checks were taking place to keep people safe in the event of a fire. However, there were key shortfalls in relation to their management of the smoking room in the home. Furniture was not always fire retardant in this room or complied with fire safety standards. People were not always smoking safely in this room, which the registered manager and staff had not identified. Some firefighting equipment was obstructed and a fire exit route had items stored in it, which posed a risk during an evacuation. The management team took action to correct these shortfalls during our assessment.

The provider made sure there were enough qualified staff, who received effective support. They worked together to meet people’s individual needs. But staff recruitment was not always complete.

There was enough staff to meet people’s needs and keep them safe. As one person said, “They [managers] are very proactive with staffing [numbers].” Care staff received supervision and training. Although not all staff received training in safeguarding people from potential abuse. Some safe recruitment checks were completed such as seeking references and confirming staff identities, but not all care staff had full employment histories. All these checks are important to ensure people are safe around staff. The registered manager said they would correct this issue.

The provider did not always assess or manage the risk of infection. They did not always identify potential infection risks and take the appropriate actions.

The home looked and smelt clean. Staff encouraged people to wash their hands at mealtimes and windows were opened to support general ventilation. But there were some infection protection shortfalls. Chipping on the main handrail on the stairs which meant this area could not be cleaned effectively, fans in people’s rooms were not always clean, and a person had a heavy build-up of limescale in their bathroom. The registered manager acted quickly to our feedback by having the flooring in this person’s ensuite replaced. They were also considering replacing the handrail following our feedback.

The registered manager made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We completed a check of people’s medicines, and found they were receiving their medicines as prescribed. People who also had mood controlling medicines had these medicines reviewed regularly by health professionals to check these were still appropriate to take. The registered manager checked staff were competent to administer people their medicines.