Elmwood 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 requires improvement. At this assessment the rating has changed to 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 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 learned to continually identify and embed good practice.

Relatives felt confident staff recognised changes in people’s needs and acted appropriately, demonstrating learning from experience. One relative told us, “They always know when [Name] is unwell and contact me and the GP straight away.”

The provider 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. We saw evidence of health care professional involvement through the care planning process.

Relatives described how learning informed people’s care from admission onwards. One relative told us, “The deputy manager came before [Name] moved in and started the care plan. They know exactly what [Name] needs.”

We received positive feedback from a visiting professional who remained involved throughout assessment processes alongside the team. They told us, “In my experience, people at Elmwood do not simply exist on a day‑to‑day basis but are actively supported to thrive.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. 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 appropriately.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

Records demonstrated people were cared for in the least restrictive way, adhering to and promoting the principles of the (MCA). DoLS authorisations were sought when needed and any conditions imposed were followed.

People told us they felt safe living at Elmwood. One person told us, “This is a wonderful place. Safe and calm and just like family. I have no complaints at all. Perfect.” A relative told us, “Absolutely I do feel that [Name] is safe here. They are very vulnerable, but I know they are safe. The staff are fantastic. The deputy manager is amazing”

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.

Records included detailed risk assessments covering falls, choking, nutrition, skin integrity,mobilityand environmental risks, all of which were up to date and regularly reviewed.

People were actively involved in decisions about how risks were managed, and care plansevidencedthe use ofleast‑restrictiveapproaches that balanced safety with independence.

Clear, practical guidance was provided for staff, for example detailed instructions relating to choking risks, including food texture, level of supervision and actions to take if risk escalated.

Allergies were clearly recorded, including confirmation of no known allergies where applicable, and wereconsideredin care planning.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People were supported to move safely around the home. Staff were attentive and proactive as people mobilised. The deputy manager ensured people used mobility aids safely and offered reassurance and encouragement.

Environmental and premises risk assessments were in place and were regularly reviewed with appropriate actions taken to reduce the likelihood of harm.

Routine environmental checks were carried out at regular intervals. Daily, weekly and monthly checks were completed and documented, and any concerns identified were addressed promptly. This helped to ensure the premises and equipment remained safe and fit for purpose.

Fire safety arrangements were robust. A current fire risk assessment was in place, and regular fire alarm tests, emergency lighting checks and fire drills were completed. Fire safety procedures were understood by staff, and plans were in place to support people safely in an emergency.

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.

Employment records were complete and well maintained. These included fully completed employment histories with any gaps explored and documented. Written contracts of employment were in place and signed by staff. There was clear evidence of an offer of employment, acceptance following interview, and detailed interview notes.

Appropriate pre‑employment checks were completed prior to staff working in the service. For staff recruited from overseas, relevant information and checks were completed and retained.

Staff received appropriate induction and ongoing support. A care induction workbook was in place and completed, supporting staff to understand their roles and responsibilities. Supervision records showed regular supervision took place.

Staff told us they had they had the right training and support. One staff member told us, “The training is very good and ongoing, we always do refresher training.”

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.

Clear infection prevention and control (IPC) policies and procedures were in place and aligned with current guidance. These were accessible to staff and consistently followed in practice.

Staff had received training and followed good hand hygiene practices and used personal protective equipment (PPE) appropriately to reduce the risk of cross‑infection. PPE was readily available, and staff demonstrated awareness of when and how it should be used.

The service monitored infection control arrangements through audits and checks. Where issues were identified, actions were taken promptly and reviewed to ensure improvements were sustained. Managers had effective oversight of IPC practices.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medication Administration Records (MAR)evidenced that medicines were administered as prescribed. Where medicines were prescribed on an “as required” (PRN) basis, clear guidance was consistently in place to support staff in making safe and appropriate decisions about administration.

For people receiving medicines via enteral feeding tubes, relevant information regarding preparation and administration was available to staff. This had not been fully consolidated into a single overarching protocol. However, the provider had recognised this and had taken action to strengthen arrangements.

Medicines were stored securely and maintained within appropriate temperature ranges. Staff administering medicines had completed competency assessments to ensure they were skilled and safe to do so. The provider also maintained effective oversight through regular medicines audits, enabling ongoing monitoring and timely identification of any issues.