Elmdale 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 people were protected from abuse and avoidable harm. This is the first assessment for this newly registered service. This key question has been rated 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. Accidents and incidents were reviewed and analysed each month. Outcomes and reflections from accidents and incidents were discussed at team meetings where learning was identified.

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. There were good working relationships with local health and care services and information was shared appropriately to ensure continuity of care and support. The provider worked collaboratively with local services to support smooth transition processes when people moved between services.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way for this to be achieved. 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 told us they felt safe in the service. Systems and processes were in place to keep people safe. Members of staff knew how to report concerns and they told us they felt confident to do so. One member of staff said, “I have access to the safeguarding policy and I always make sure I know and understand the safeguarding policy and follow this at all times. If I suspected abuse, I would ensure the person who I am supporting is immediately safe from harm, report it straight away to my manager/on call (if the concern happens outside of working hours), and if there is an urgent risk report it to the emergency services. I would then complete the relevant paperwork in regard to this concern making sure the account is factual and does not contain any opinions or assumptions. If the concern involved my manager, I would report this to senior management team or the local safeguarding authority.”

We saw evidence the provider understood the principles of the Mental Capacity Act 2005 (MCA) in relation to reviewing people’s capacity and understanding around receiving care and support. The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. 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 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found the service was working within the principles of the MCA and, if needed, appropriate legal authorisations were in place to deprive a person of their liberty.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. People’s care plans were detailed and person-centred. Potential risks were clearly assessed and mitigating actions were in place. Care plans specific to people’s individual health conditions were detailed and daily records were clear and concise. Care was delivered in line with people’s care plans.

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 provider carried out regular checks of the environment to ensure it was safe. Records were well organised and maintained. Where potential risks had been identified, mitigations were in place to reduce the risk.

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 which met people’s individual needs. Members of staff were recruited safely and all pre-employment checks completed appropriately. Staff were deployed effectively to meet people’s identified needs and gender preferences. Training opportunities and supervision sessions were in place for the staff team. A member of staff told us, “I feel staffing levels are adequate for the people we support. There is also good communication between staff during handovers, which helps us maintain good levels of care. If I ever felt unsafe with staffing levels, I would feel comfortable reporting this to the deputy manager or registered manager.”

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 care environment was clean and well-maintained. Members of staff confirmed they had access to personal protective equipment (PPE) and infection prevention and control (IPC) training. A member of staff said, “I have access to PPE and I know where this are stored. I understand when PPE needs to be worn and I also know to contact the deputy manager if we ever need stocking up on PPE. I completed the mandatory infection prevention and control course as part of my induction and refresh this regularly. The training covered hand hygiene, food hygiene, use of PPE, cleaning and decontamination, safe disposals and recognising and responding to outbreaks. I demonstrate IPC daily by ensuring the household is clean, using PPE correctly and monitoring food temperatures.”

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Administration of medicines was managed safely. All members of staff were trained to administer medicines, this included specialist training to administer rescue medication appropriately following epileptic episodes. Clear protocols were in place to manage epileptic episodes effectively and members of staff were able to explain the protocols and processes to us. There were no concerns about and no evidence of over-medication or inappropriate use of medication.