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Elmsdene Care Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 15 October 2020

About the service

Elmsdene Care Home is a residential care home providing personal care to people aged 65 and over. The home specialises in providing care for people who live with dementia. The accommodation, which is on the ground and first floor, consists of twenty-five single bedrooms, nine of which have en-suite facilities and four double bedrooms, two of which have en-suite facilities. The communal space consists of a large dining room, lounge area and a separate television lounge. At the time of our inspection visit there were 21 people who lived at the home.

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

The service was not always well-led. At this inspection we identified issues with the provider's quality and assurance systems. Some records relating to care and the management of the service were either incomplete, inaccurate and/or not kept up to date. This could have compromised the quality and safety of the service provided.

The service was not always safe. The provider had not ensured a sufficient number of suitably trained staff were deployed at all times to ensure people’s safety. People did not always have risks to their personal safety identified and recorded. When they had been identified, control measures were not always documented to mitigate the risk. Staff were able to tell us about the risks to people and knew how to support people to minimise the risks. We found some issues with the cleanliness and maintenance of the environment. We have made a recommendation around infection prevention and control. The home had an adequate supply of personal protective equipment.

There was a positive staff culture at the service and staff told us they enjoyed their jobs. One staff member told us, “It is one of the nicest homes I have ever worked in, the residents are beautiful, it’s a good team.” We spoke to one relative who told us, “We are more than happy with the care provided which is what is important to us.” Another said, “We are kept informed and updated and know that our relative is happy.”

We found the management team receptive to feedback and keen to improve the service. The registered manager and provider worked with us in a positive manner and provided all the information we requested. Additionally, they responded immediately to our concerns during and after the inspection.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was good (published 18 November 2018).

Why we inspected

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. We carried out this targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about staffing and risk management. A decision was made for us to inspect and examine those risks. 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 inspected and found there was a concern with staffing, training, risk management, documentation and governance, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report. The provider submitted an action plan after this inspection to show what they would do and by when to mitigate the risks and improve.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Elmsdene Care Home on our website at


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to staffing and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 15 October 2020

The service was not always safe.

Details are in our safe findings below.



Updated 15 October 2020



Updated 15 October 2020



Updated 15 October 2020


Requires improvement

Updated 15 October 2020

The service was not always well-led.

Details are in our well-Led findings below.