Elm Tree House

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 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.

Effective systems were in place to record, monitor and review incidents. The manager provided an example of learning following a medicines error involving a pharmacy. The incident was investigated, actions were taken to reduce future risks, and the learning was shared across the wider organisation to help prevent similar incidents occurring elsewhere.

Staff told us they regularly took part in safety huddles and debriefs following incidents. These discussions gave staff opportunities to reflect on what had happened, identify any improvements needed and share good practice. This helped to ensure learning was embedded and used continuously to improve outcomes for people using the service.

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.

People’s needs were assessed before they began using the service. Information was shared appropriately when people moved between services, for example, hospital plans for people. Staff liaised with healthcare professionals and followed their guidance to support safe and consistent care.

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.

Staff told us they received training in safeguarding adults from harm and abuse. One staff member said, “I have raised safeguarding and followed the process from start to finish. We have completed safety huddles and learnt from our mistakes. I feel like you shouldn’t be scared to raise a safeguarding I know for me we should be open and honest that’s how we learn and grow ensuring that if mistakes happen, we learn from them and make changes where we can.”

One relative said, “[Relative’s name] is in a good place. It's safe.”

Up until June 2026, people could 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. We found that staff and management worked within the MCA. DoLS authorisations were appropriately applied for and overseen. People were not subject to unlawful or excessive restrictions. They had choice, control and freedom over their lives.

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.

Relatives said they were involved in care planning, risk assessments and reviews and felt their views and advice were listened to and valued.

Care plans and risk assessments contained a good level of detail, clearly identifying people's likes, dislikes, strengths and support needs. However, it was noted that references to allergies or intolerances required clarification for one person. The manager said they would review these to ensure they accurately reflected people’s needs. Staff demonstrated a good understanding of risks relating to people’s eating and drinking needs and the support required to keep people safe.

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

The environment was safe, homely and personalised. One relative said, “It's a safe good environment and it suits [Relative’s name].”

There were measures to reduce the risk of fire. Fire safety equipment was regularly serviced and maintained, and people and staff took part in fire evacuation drills to help ensure they knew what to do in the event of an emergency.

Regular health and safety checks were completed to monitor the safety of the environment and to identify any areas requiring attention. People had personal emergency evacuation plans (PEEPs), which provided guidance on the support they would need during an emergency. During the inspection we found these plans did not include information about whether people used flammable creams, which could be relevant in the event of a fire. The provider responded positively to this finding and told us they would update the plans and share the learning across the wider organisation to support consistent practice.

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.

Staff were recruited safely. Checks included those with the applicant’s previous employer and with the Disclosure and Barring Service (DBS). DBS checks are important as they inform employers of an applicant’s previous criminal history and if they are on the barred list.

Staff received training relevant to their role and supervisions took place regularly to support staff in their role.

The provider has now reviewed staffing levels to ensure there is a systematic approach to deploying staff across the service, in line with people’s needs.

Staffing levels now met people’s needs. One staff member commented, “I think we have the correct staffing levels and our teamwork is fantastic. If someone is off sick, we get the shift covered in house which just shows no agency is required which is great for the people who live at Elm tree as they like to know exactly who is working on what days.”

One person said they liked the staff and another person told us staff knew them and understood them well. One relative said, “They have more permanent staff. The turnover is less now.”

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.

During the inspection, we found the home was clean, well maintained and hygienic. Measures were taken to reduce the risk of infection spreading, helping to keep people, staff and visitors safe. Staff had completed infection prevention and control training and understood their responsibilities for maintaining a safe and clean environment.

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.

Medicines were administered by staff who had received appropriate training whose competency to administer medicines had been assessed. We reviewed medicines administration records and found they had been completed correctly, showing people had received their medicines as prescribed.

Some people were prescribed medicines to be taken ‘as required’ (PRN), clear guidance was available for staff. This helped ensure people received these medicines safely and concisely when needed.

Records for prescribed creams and other topical medicines provided clear instructions about where they should be applied. Medicines were stored securely and in line with safe practice.