The Elms

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 remained good. This meant people were safe and protected from avoidable harm.

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 service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Staff knew how important it was to report accidents and incidents and felt confident to speak up about any concerns. The registered manager had clear processes in place to review incidents, learn lessons and lower risks to people. Staff described the workplace as positive, where regular training, supervision and reflection were encouraged. They said they felt well supported by the registered manager and were able to share suggestions to improve care. Relatives were kept up to date about any changes. The registered manager had a comprehensive understanding of people’s needs and maintained effective oversight of the care delivered.

The service 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.Relatives and staff said care decisions were clearly explained and referrals were made promptly when needed. The registered manager had effective working relationships with external professionals. One professional commented, “The service feels very much like their home and people presented as comfortable and at ease in the environment. The staff seemed knowledgeable about the people I was assessing and clearly had a good working relationship with each of them.’’ Regular team meetings gave staff the opportunity to openly discuss care and safety.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. People told us they felt happy, safe and cared for. One person said, “I’m happy here.’’ Relatives also said they trusted the service. One relative said, “I have always been very pleased with the excellent care provided.’’ During the inspection, we observed staff working in a safe and kind manner. Safeguarding procedures were in place, and staff told us they knew how to report concerns and trusted the registered manager to respond quickly and appropriately. The registered manager had comprehensive knowledge of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. The service followed the principles of MCA and all DoLS applications were managed in line with regulatory requirements. The registered manager kept oversight of authorisations, and staff received training to help protect people from harm.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.People had care plans and risk assessments in place to support staff while encouraging independence and choice. People were supported to take positive risks, such as going out into the community and participating in activities they enjoyed. Staff carefully supported people who felt anxious or distressed so they could still enjoy meaningful activities. During the inspection we observed people returned from an outing looking happy and relaxed.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.People and their relatives spoke positively about the service and said it felt homely, clean, and well looked after. The environment was suitable and comfortable for people to meet their needs in communal areas. Staff were warm and supportive, which helped create a relaxed atmosphere. The registered manager ensured the environment was safe, with clear systems in place to identify and manage risks. Maintenance staff were trained in areas such as fire safety and health and safety, and external contractors caried out regular checks, including gas and fire safety. Fire drills, including nighttime evacuation, were held regularly and each person had up to date personal emergency evacuation plans.

The service 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. Procedures were in place to ensure the required checks were carried out on staff before they commenced their employment. This included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions. There were enough staff to support people safely. People and their relatives said they were happy with the care provided. One relative said, “Staff treat our loved one kindly and our loved one is always pleased to see them after being home with us.’’ People were supported to make choices about their daily activities. Staff completed training in areas such as learning disabilities, autism, and positive behavioural support. A staff member said, “We’ve done a lot of mandatory training and more specific training too. If we need extra training, they are happy to provide it.’’ Staff received regular supervision, appraisals, and a structured induction, which helped them to develop the skills and confidence needed to provide safe and effective care.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.Staff completed training in infection prevention and control (IPC) and had access to suitable personal protective equipment (PPE). The environment was clean, tidy, and well-maintained, and people were confident in the hygiene standards. Robust IPC practices were part of daily routines, supported by regular audits to ensure continued safety and compliance.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. People received their medicines as prescribed, and staff followed safe medicines practices. Guidance was in place for medicine taken ‘as required’. Medicines were administered safely, taking into account people’s needs and preferences. Stock levels were accurate, and people were involved in planning how they received their medicines. Safe procedures were used for ordering, storing, administrating, and disposing of medicines. Staff received training, regular competency checks, and management audits checked for shortfalls.