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The Elms Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 9 September 2021

About the service

People and relatives mainly spoke positively about the quality of care and the kindness of staff. However, systems to safely recruit staff were not sufficiently rigorous which placed people at risk of receiving care from staff with unsuitable experience and backgrounds.

People’s experience of using this service and what we found

People and relatives mainly spoke positively about the quality of care and the kindness of staff. However, systems to safely recruit staff were not sufficiently rigorous which placed people at risk of receiving care from staff with unsuitable experience and backgrounds.

Some improvements had been achieved in relation to how people were supported with their medicines; however additional areas of improvement with medicine practices were needed to ensure people’s safety.

Improvements were needed to the infection prevention and control practices to consistently ensure people’s safety.

People were supported by staff who understood how to protect them from abuse and harm. Allegations of abuse were reported to the appropriate authorities.

Risks to people’s safety were identified and guidance was developed to address these risks.

People received care that was personalised and planned in accordance with their needs and wishes.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff received training and support from the provider to meet people’s needs, although there were mixed views from staff about the quality of support and guidance.

People and relatives told us the management team were approachable and responsive.

Monitoring and auditing systems were in place to identify and remedy any issues with the quality of the service. However, we found shortfalls across a range of areas including medicine management and staff recruitment which were not identified by the provider’s own quality assurance checks.

The registered manager was provided with additional support and mentoring since the last inspection to carry out their responsibilities. Findings at this inspection demonstrated this was an on-going need.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The rating for this service was Inadequate (published 30 December 2020) and has been in Special Measures since this date. There were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do to improve and by when. During this inspection the provider demonstrated some improvements have been made and they have met some of the breaches of regulation. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This focused inspection was carried out to follow up on action we told the provider to take at the last inspection and confirm they now met legal requirements. This focused report covers the entirety of the key questions Safe and Well-Led but only parts of the key questions Effective and Responsive, which were found to be in breach of regulations at the last inspection. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection. Please

Inspection areas

Safe

Requires improvement

Updated 9 September 2021

The service was not always safe.

Details are in our safe findings below.

Effective

Good

Updated 9 September 2021

At our last inspection we rated this key question good. We have not reviewed the rating at this inspection. This is because we only looked at the parts of this question we had specific concerns about.

Caring

Good

Updated 9 September 2021

Responsive

Good

Updated 9 September 2021

At our last inspection we rated this key question good. We have not reviewed the rating at this inspection. This is because we only looked at the parts of this question we had specific concerns about.

Well-led

Requires improvement

Updated 9 September 2021

The service was not always well-led.

Details are in our well-led findings below.