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Archived: The Elms @ Kimblesworth Requires improvement

The provider of this service changed - see new profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 5 June 2018

This inspection took place on 28 and 29 March 2018. We planned to undertake an unannounced focused inspection as a result of receiving information of concern about the running of the service. This inspection was carried out to check to see if the concerns were accurate, and also to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection in August 2017 had been made. We intended to inspect the service against the key questions – is the service safe, is it effective and is it well–led. As continued concerns were found across the five key questions we changed the inspection to a comprehensive inspection.

At our last inspection in August 2017 we found breaches of regulations 11, 12, 13, 17, 18 and 19. The breaches related to the provider failing to meet the requirements of the Mental Capacity Act, ensuring people were cared for in a safe manner, staff were provided with the necessary support to carry out their roles and they had been appropriately vetted before they began working in the home. We also found the provider had failed to ensure there were sufficient and robust governance arrangements in place. The manager provided us with an action plan to show us what actions they were taking to continue with the improvements. At this inspection we found improvements had been made although we found there were continued breaches of Regulations 12, 17 and 18.

The Elms @ Kimblesworth is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of the inspection there were 14 people living in the home.

At the time of our inspection a new manager who subsequently became the registered manager had begun to make improvements. They provided us with an action plan to show us what actions they were taking to continue those improvements. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Security of the building needed to improve. Inspectors were able to access the building and people’s personal information undetected at 6.30am. The manager told us they would issue new guidance to staff which ensured greater security.

People were given their medicines in a safe manner. However we found improvements were required in the home to support people who had been prescribed topical medicines (creams applied to the skin).

During our last inspection we found a breach of Regulation 18 as staff had not received appropriate support through induction, training supervision and appraisal. At this inspection staff records showed there was a continued regulatory breach. Staff had not received supervision and training in topics relevant to their work.

Audits to measure the quality of the service failed to identify the deficits we found during our inspection and monitor the service across regulatory requirements. The service had yet to reach the stage where the outcomes of surveys, complaints and compliments drove improvements to the care provided to people.

Work had been carried out to make improvements to the cleanliness of the building and reduce the risks of cross infection. Further work was required to the home to complete this task.

The fire risk assessment had been updated and there were regular checks carried out on, for example, firefighting equipment and alarms. However we found a number of concerns about fire safety and asked the local fire safety officer to visit the home. The fire safety officer reported they had found a number of deficits and the area manager and the manager had agreed to address these.

At our last

Inspection areas


Requires improvement

Updated 5 June 2018

The service was not always safe.

Arrangements were not in place in the service to monitor and ensure people received their prescribed topical medicines (creams applied to the skin).

Following the inspection we asked the fire safety officer to visit the premises as we had concerns regarding fire safety including exit routes from the building and garden. They told us they had found a number of deficits and would be carrying out a further visit to find out if the provider had made improvements to the premises.

There were enough staff on duty during our inspection to meet people�s needs.


Requires improvement

Updated 5 June 2018

The service was not always effective.

Staff were not given appropriate support through training, supervision and appraisal.

Capacity assessments had been carried out and applications had been made to the local authority to deprive people of their liberty and keep them safe.

People reported to us they enjoyed the food provided in the home. Kitchen staff were aware of people�s dietary needs and how people preferred to manage their diets.


Requires improvement

Updated 5 June 2018

The service was not always caring.

The premises and people�s confidential information were not always secure.

Staff were kind and caring towards people who used the service. They chatted with people and understood their likes and dislikes.

People�s independence was promoted by staff.


Requires improvement

Updated 5 June 2018

The service was not always responsive

People�s care records required further improvement to ensure they were accurate and up to date.

Staff had addressed people�s end of life preferences as far as possible and respected people�s wishes not to discuss the topic if that was their preference.

Staff supported people to carry out their preferred activities.



Updated 5 June 2018

The service was not well-led.

Although improvements had been made since our last inspection to documentation used in the home we continued to find documents which were not up to date or accurate.

Arrangements which were in place to monitor and improve the service failed to identify the deficits we found during our inspection.

The service worked in partnership with other professionals to meet people�s needs.