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Inspection Summary

Overall summary & rating


Updated 18 April 2018

This unannounced inspection of Elmdene Care Home took place on 8 March 2018. Elmdene is a ‘care home’ for adults with mental health problems. 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. Elmdene care home accommodates five people in one adapted building.

At the last inspection of Elmdene on 25 October 2015, the service was rated Good overall, although, we found that robust checks were not always completed around recruitment of staff. We asked the provider to comply with this requirement. At this inspection we found the service had made the required improvement and their rating remained Good.

There was no registered manager in post. The provider was in the process of registering to become the registered manager. 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.

Staff employed at the service had undergone thorough checks to ensure they were fit to work with people. Staff and the provider were committed to protecting people from abuse. Staff were trained in safeguarding people from abuse and demonstrated that they understood the signs of abuse and how to report any concerns in line with the provider’s procedures. There were sufficient numbers of staff to support people at the service. Risks were assessed and management plans were developed to mitigate any risks identified. Staff followed risk management plans for people.

People’s needs were assessed with involvement of relevant professionals where required to ensure their needs were met. Support plans focused on meeting people’s individual needs and goals. People were supported to learn new skills, develop their interest, become independent; and move-on to independent living. People were supported to do the things they enjoyed and gain meaningful and paid occupation. Regular reviews took place to ensure support delivered to people continued to meet their needs.

People’s medicines were managed and stored in a safe way. Health and safety of the environment was maintained. Staff followed good infection control procedures. Staff reported incidents. The provider reviewed and took actions to prevent them from happening again. Lessons were shared with staff.

Staff were trained, supervised and had the skills and knowledge to meet people’s needs. People’s nutritional and dietary needs were met. People were encouraged to cook for themselves. Staff worked effectively with health and social care professionals to attain positive outcomes for people. People had access to healthcare services to maintain good health. The service had systems in place to enable smooth transition when people moved between services. There were suitable facilities and adaptations available for people to use.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff understood their responsibility under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. People knew how to make a complaint if they were unhappy with the service. The provider investigated complaints in line with their procedure.

Staff understood people’s needs and treated them with respect, kindness and dignity. Staff supported people to express their views and people were involved in planning their care and support. People were supported to maintain their religious and cultural values.

Staff received the support, direction and leadership they needed. There were systems in place to monitor and assess the quality

Inspection areas



Updated 18 April 2018

The service was safe. The risks to people were assessed and actions put in place to ensure they were managed appropriately.

Staff understood how to recognise abuse and how to report concerns following the organisation�s procedures.

There were sufficient number of staff on duty to meet people's needs.

People received their medicines safely. The home was clean and infection control procedure was followed.

Lessons were learned from incidents and when things go wrong.



Updated 18 April 2018

The service was effective. People's care and support needs were assessed and staff received training, support and supervision to appropriately support people with their needs.

People gave consent to the care and support they received before they were delivered. The service knew their responsibility under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

People had access to food and drink of their choice and were supported to eat a healthy diet.

People were supported to access healthcare services to meet their needs. The service ensured people had a well coordinated care and support.

People had facilities they needed. They had their individual rooms and spaces to relax.



Updated 18 April 2018

The service was caring. People were treated with dignity and their privacy was respected by staff. Staff showed compassion and care in the way the attended to people.

Staff understood the needs of people and how to support them. People were involved in planning their care and support and their wishes respected.

People were encouraged and supported to maintain their independence.



Updated 18 April 2018

The service was responsive. The service met people�s individual needs and requirements; and recover from their conditions. People were supported to develop new skills for daily living, and gain meaningful occupation. People were supported to move on to independent living services.

People engaged in activities they enjoyed and stimulating to them.

People knew how to complain if they were unhappy the service.



Updated 18 April 2018

The service was well led. People and staff told us that the provider was approachable and open to new ideas. Staff felt well supported and involved in running the service.

There were systems in place to monitor and assess the quality of service provided.

The service worked in partnership with other agencies and community services to provide an effective service to people.