The Elms Care Home

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.

The service was in breach of legal regulations in relation to people’s safe care and treatment and safeguarding people from abuse.

This service scored 50 (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.

Accident, incidents and near misses were recognised by staff and reported to management. The manager reviewed accidents and incidents and considered why these may have occurred and what may be done to reduce further occurrences. For example, if people had sustained falls, their care plans and risk assessments were reviewed and updated. Additional measures were put in place for people who were at risk of falling, such as sensor mats which would provide staff with an early warning of when people were mobilising and enable them to provide timely support.

The staff met daily where they discussed any accidents, incidents and changes to people’s needs. This meant that staff had up to date knowledge of people’s needs and could provide consistent support.

The provider worked with people and healthcare partners to establish safe systems of care. People had robust assessments prior to moving into the service.

The leadership team showed clear understanding of the company’s policy and procedure, they were aware that they would only admit people to the service after completing a full assessment. This meant people had robust assessments completed before they moved to the service. Staff were able to read the assessments completed prior to people being admitted. This gave them an understanding of people’s needs, how they liked to be supported, and how to recognise any changes in people’s needs following admission so that any concerns could be escalated to the relevant medical practitioner in a timely way.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety free from abuse, discrimination, avoidable harm and neglect.

The provider failed to ensure that people received food that was modified in-line with their assessed need, which placed them at risk of harm. We observed people being served food at the incorrect texture, for example, where a person was assessed as requiring a minced and moist diet, they were served food that was not modified to this level, which placed the person at increased risk of choking. Whilst the provider was responsive to our concerns and took immediate actions to ensure people had their food prepared in line with their assessed needs, we raised a safeguarding concern to the local authority team.

People had to ask staff if they wanted to go outside or to access the local community, this included people who had capacity and understood the associated risks of going out alone. This meant people were being unlawfully restricted. The provider was responsive to our concerns and was looking at ways to balance freedom of movement and home security.

The management team and the staff all had a clear understanding of their responsibilities in the event of suspected abuse or neglect. The management team had been working with staff to recognise the benefits of reporting safeguarding concerns.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider failed to have effective systems and processes in place to ensure that people’s dietary needs were consistently met. People who were at risk of malnutrition or were diabetic did not always receive food in line with their assessed needs. For example, people who needed fortified food, to increase their calorie intake, were served the same food as people who needed their calorie intake reduced. This meant people were at risk of their health conditions deteriorating. The service was responsive to our concerns and developed ways of ensuring people had food in line with their assessed needs.

Staff did not always use safe manual handling techniques, for example we saw staff assisting people to stand by placing their hand under the person’s armpit. This meant people were at increased risk of injury.

People’s daily notes did not always contain enough information to enable staff to monitor the effectiveness of their care. For example, people’s meals were recorded, but this didn’t always detail the actual portion size of the meal consumed. This meant that staff would not be able to see if people were having adequate nutrition in line with their assessed needs. The provider was aware of this prior to our assessment and had an action plan in place to resolve the concern.

People’s initial assessments were robust. However, people’s care plans were not always completed accurately and sometimes contained contradictory information. This meant the information for staff was not always clear, accurate or consistent and people’s care plans were not always effective. This increased the risk of people not receiving the care they needed, which increased the risk of people’s medical conditions declining and impacting on their health and wellbeing. The provider was aware of this prior to our assessment as they had identified that some people’s care plans were not always accurate or contained detailed information for staff and was reviewing people’s care plans to ensure they were accurate and robust.

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.

Fire safety was not always well managed and fire safety checks were ineffective in identifying the concerns we found on this inspection. For example, some fire doors had gaps and did not always close fully. Fire drills had not been completed in line with the actual number of staff on duty during various shifts and records failed to demonstrate that fire drills were simulated to ensure staff were adequately prepared in the event of a fire. We made a referral to the local fire and rescue services. We discussed this with provider, and they were very responsive to our concerns, they repaired the fire doors and arranged additional staff overnight. Furthermore, they were planning to carry out fire drills with the actual number of staff on shift.

The provider had not always ensured people’s safety by preventing access to hazardous areas of the environment. For example, doors to cupboards containing hazardous chemicals, hot water pipes, boilers and electrical switch boards were frequently left unlocked. The door to the servery which contained a bain-marie that was hot, and a boiler was frequently left open. This meant people were at risk of harm. The provider was responsive to our concerns and put systems in place to ensure these doors were kept locked. This needed time to be embedded into practice.

Some people were not able to call for assistance in an emergency. For example, some people had sensor mats placed outside of their bedroom doors with their call bell attached to the mat. This meant they were unable to summons help and support from staff. This also posed a trip hazard due to trailing cables on the floor outside people’s bedroom doors. The Provider was responsive to our concerns and ensured people had access to their call bells and that any cables were positioned appropriately.

There were robust systems in place to ensure the equipment, water supply, electrical items, hard wiring and gas supplies were safe in line with the providers policy and legislation.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

The provider had not always ensured that agency workers were employed in accordance with current legislation which placed people at risk of receiving unsafe care. When we raised this with the provider, they immediately gained the required documentation. Staff directly employed by the service had been employed safely and in accordance with current legislation.

We could not be assured there was always enough staff to efficiently meet people’s needs. For example, call bells were not always responded to promptly, and records showed there were significant delays at times. Staff frequently failed to record the care they had provided at the time it was given. which meant we could not be assured people had the care they required in a timely way.

Whilst the service had a dependency tool in place, people’s support hours were set by their assessed category of need rather than based on their specific requirements. Some people’s dependency assessments did not accurately reflect the level of support they required meaning some people were not always receiving the correct level of support to safely meet their needs. The provider was aware of this and had an action plan in place, they were in the process of testing alternative dependency tools at other locations. This needed time to be embedded into practice.

The provider failed to assess or manage the risk of infection. They did not control the risk of it spreading.

We could not be assured that systems to prevent and control infection were robust or effective, as we identified concerns with infection control practices and the cleanliness of equipment within the home. For example, staff didn’t always adhere to the providers’ personal protective equipment (PPE) policy and procedures, and we observed staff handling offensive waste without wearing PPE and providing personal care without washing their hands. Where there was a suspected infection outbreak, staff did not always follow processes.

Equipment was not always clean and the house keeping trolley was sometimes observed in the dining area during mealtimes. This increased the risk cross contamination and infection spreading.

The home manager told us they had recently implemented a new cleaning schedule and were planning on implementing an infection control champion to ensure staff followed correct processes. However, at the time of this inspection, this had not been embedded into practice.

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

Medicines including controlled drugs (CDs) and medical oxygen were stored securely. However, the CD cupboard was not compliant with the legislation. Revised in-use expiry dates and or date of opening were added to most relevant medicines. Temperature recording processes were recently updated. Minimum, current and maximum fridge and current room temperature records were kept. However, whilst out of range fridge temperatures had been recorded, there was no evidence of actions taken when temperatures were out of range. When we raised our concerns about the safe storage of medicines, the manager and senior team developed an action plan to address our concerns.

Most people’s records contained information about how they preferred to take their medicines. These records included additional information which supported staff to administer when required and variable dose medicines. However, some were not individualised and did not describe how one medical condition was managed with multiple medicines. There were limited information and guidance to support staff on what medicine to administer, when and what doses.

Information about the fire risk associated with creams, ointments and medical oxygen were described in people’s care plans and the evacuation plan for the location. Creams applied by care staff were recorded and the record detailed where the product was applied, but the name of the product was not recorded. Although staff showed robust knowledge of the cream’s individuals used, this did not fully mitigate the risk of error.