Elmcroft 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 inspection we rated this key question requires improvement. At this inspection the rating has changed to good. This meant people were safe and protected from avoidable harm.

At our last inspection the provider was in breach of the of legal regulations in relation to safeguarding. Improvements were found at this inspection, and the provider was no longer in breach of this regulation.

This service scored 69 (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 and managers listened to concerns about safety and reported safety events appropriately. The registered manager had a robust process in place to analyse incidents and accidents in order to identify trends and themes and improve outcomes for people. Actions and lessons learnt were shared with staff to promote learning and embed good practice.

The provider worked collaboratively with people, relatives and health professionals to establish and maintain safe systems of care. Safe processes were in place to support transitions for people being admitted into the service and moving between different health and social care settings. The provider shared information appropriately and made sure there was continuity in people’s care as they transitioned between services.

The provider worked in partnership with people and healthcare partners to understand what being safe meant to them and the best way to achieve this. Staff 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 provider shared concerns quickly and notifications were submitted appropriately. There was a safeguarding policy and process in place and staff had received safeguarding training.

Staff were aware of how to recognise potential signs of abuse and knew how to raise safeguarding concerns. Comments included, “If I have any safeguarding concerns, I will first discuss them with my manager. If nothing has been done, I will take it to the local authority or CQC” and “I would immediately raise it with the nurse in charge or a member of the management team. If required, I would escalate the concern further in line with safeguarding procedures.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people’s safety were assessed and reviewed. However, we found people’s risk assessment documentation did not always contain sufficient personalised information about their health conditions and risk management. For example, we found risk assessments relating to people’s skin integrity, nutrition, diabetes, Parkinson’s disease and mental health required greater detail.

Despite these concerns, people were supported by an established and consistent staff team who knew them well. People told us they felt safe and people’s relatives had no concerns about their safety. Following our feedback, the provider responded promptly to review and update the relevant risk assessment documentation.

The provider had some processes in place to detected and control potential risks in the care environment. However, during the site visit we found not all risks had been identified and addressed. For example, we found very hot, uncovered and degraded radiators in communal areas, including near to a dining table where people were seated. This posed a potential burns risk. We also a found trailing extension cable in the dining room which posed a potential trip hazard. The provider responded immediately during the site visit, arranging for maintenance works on the radiators and removing the cable. Following our feedback, the provider confirmed they were reviewing their environmental monitoring processes to ensure they were more robust.

At the time of the inspection, the building was undergoing essential maintenance work to ensure health and safety compliance. The provider had a schedule of planned work in place and was able to demonstrate how they were continuously monitoring the risks and potential impact of the works to ensure people remained safe.

The provider 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. The provider had completed appropriate recruitment checks to ensure staff were safely employed. However, minor improvements were required in relation to checks on applicant’s previous care positions. Following our feedback, the provider confirmed additional measures had been implemented with immediate effect.

People and their relatives spoke positively about the consistency of the staff team and their knowledge of people’s needs. Comments included, “They know all about [person] and know exactly how they want to be supported” and “I’m not sure there are any agency staff to be honest, I see the same staff.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The service was generally clean and hygienic and there was ongoing refurbishment work to further improve the environment. Staff had received infection prevention and control training and we observed staff wearing appropriate personal protective equipment when required.

The provider made sure people’s medicines were safe and met their needs. Medicines were well organised, with medicines administered in line with relevant clinical guidance. Records and administration charts were consistent, and staff demonstrated a clear understanding of safe medicine handling procedures. People’s medicines were given in line with their individual needs and preferences and we received positive feedback about how medicines were managed. One relative told us, “Medicines are much more coordinated now, looking back the improvement since the new manager is massive.”