Elm Lodge Residential Care Home

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question good. At this assessment our rating has changed to inadequate. This meant services were not planned or delivered in ways that met people’s needs.

The provider was in breach of legal regulation in relation to person centred care.
 

This service scored 32 (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 did not ensure care was consistently person-centred or responsive to people’s individual needs. Care plans were not accurate, complete or reflective of people’s current circumstances, which meant staff did not have clear or reliable guidance on how to support people.
Although care plans had been reviewed regularly, this had not ensured the information recorded was correct. We found inconsistencies and contradictions within records. For example, 1 person’s care plan stated medicines were to be administered covertly; however, daily records contradicted this, and staff were unable to clarify the correct approach. The same person’s records stated they required a daily shower, yet there was no evidence this had been provided for several weeks.
Risks and changing needs were not appropriately reflected in care plans. One person identified as being at risk of leaving the service did not have guidance in place to manage this risk. Another person had a deteriorating skin condition, but there was no information outlining how staff should support them or reduce the risk of further deterioration, despite them spending extended periods in bed.
Daily records were not consistently maintained. We found significant gaps in monitoring, including personal care, safety checks and food and fluid intake. This meant there was no clear oversight of whether people’s needs were being met.
People were not consistently supported to engage in meaningful activity. There was no dedicated activity provision in place, and we observed people sitting disengaged for long periods on both days of the assessment.
There were some examples of person-centred information recorded within care plans. For example, 1 person’s records included detailed information about their family relationships and how staff could support meaningful conversations. However, this was not consistent across the service or reflected in day-to-day practice.
The provider had not ensured care was planned and delivered in a person-centred way, resulting in inconsistent support and poor experiences for people.
 

The provider did not ensure care provision was coordinated, responsive or based on a clear understanding of people’s needs. There was a lack of effective oversight and leadership to ensure care was delivered safely and in line with people’s needs and preferences.
The provider did not demonstrate a sufficient understanding of adult social care or how to meet the diverse needs of people using the service. During both days of assessment, the provider was not visible to people or visiting professionals and did not take a proactive or hands-on role in overseeing the delivery of care. This meant there was no effective monitoring of care provision or assurance that people’s needs were being met.
Joined up working with relatives and external professionals was not effective. There was no clear evidence feedback, assessments or input from others had been considered or incorporated into care delivery. For example, staff told us a district nurse had visited the service; however, they were unable to confirm who had been seen, the reason for the visit or what care or treatment had been provided. Care records did not document the involvement or outcomes of this visit, and communication with relatives was inconsistently recorded or absent.
People did not always receive timely care and treatment from external professionals. Referrals were not consistently made when people’s health deteriorated, and staff did not always seek advice when concerns arose. This lack of coordination resulted in delays to care and, in some cases, avoidable deterioration and escalation of people’s health needs.
Care was not always delivered in line with people’s preferences. Although some care plans identified people’s wishes to access community groups and local amenities, there was no evidence these had been supported or facilitated. This meant people were not enabled to maintain their interests, independence or connections with their community.
 

The provider did not ensure people were consistently supported to access information in a way that met their individual needs. While some information about people’s communication needs was recorded, this was not consistently embedded into practice or supported by effective systems.
Although no formal requests for information in alternative formats had been recorded, the provider was unable to demonstrate how such requests would be managed. During both days of assessment, the electronic care system was not functioning effectively, and senior staff were unable to access care records. This meant important information could not be shared or reviewed when required.
Record keeping was not robust, and we saw limited evidence of people or their relatives being involved in care planning. Due to gaps in records, we could not be assured whether requests for information had been made or responded to appropriately.
Accessible information was not routinely available within the service. One person was registered blind, but the service had no alternative or appropriate methods of communication to aid their involvement. Menus were not provided in pictorial or accessible formats to support people living with cognitive impairments. We also saw no examples of policies, procedures or guidance being adapted into accessible formats.
However, care plans did include information about people’s communication needs, such as whether they required glasses, hearing aids, or experienced difficulties communicating.
 

The provider did not have effective systems in place to listen to and involve people, relatives or staff in decisions about care and the running of the service. There was a lack of evidence to demonstrate feedback was sought, acted upon or used to improve care.
The provider was unable to demonstrate consistent methods for gathering feedback. There were no people or staff surveys in place. Although some relative surveys had been completed, these had not been collated, were undated, and there was no evidence of analysis or action planning. This meant the provider could not demonstrate how feedback had been reviewed or used to improve the service.
Records of meetings were limited and not effective. We found evidence of a service user meeting held on 11 March 2026, where people expressed a wish for more regular access to a hairdresser. However, meeting minutes were minimal, and there was no evidence of actions being taken or outcomes achieved. Staff told us they had not attended staff meetings for a significant period of time and could not recall when the last meeting had taken place.
The provider did not maintain clear records of complaints or compliments. This meant we could not be assured concerns were being identified, investigated or responded to, or that positive feedback was used to recognise good practice.
Care records did not reflect peoples lived experiences within the service. Despite observations of people appearing disengaged and, at times, distressed, this was not consistently recorded or explored. This meant there was no evidence people’s views or experiences had been recognised, discussed with them or their representatives, or used to inform improvements in care delivery.
 

The provider did not ensure the service was accessible for all people or that reasonable adjustments were made to meet individuals’ needs. Barriers within the environment and systems limited people’s ability to access all areas of the service and receive equitable care.
The layout of the service did not support people with reduced mobility. There was no lift available, and access between floors relied on a stair lift. This meant people who became less mobile were restricted in how they could access different areas of the service. For example, people who were unable to use the stair lift would be required to remain on the ground floor or in their bedrooms, limiting their opportunities to access communal spaces and social interaction.
The provider had not made sufficient environmental adaptations to support people living with dementia or sensory impairments. We observed a lack of dementia-friendly signage, including on bedroom doors, which made orientation more difficult for people and could increase confusion or anxiety. We observed this during assessment site visits, whereby multiple people were walking around the service unable to locate their bedrooms or orientate themselves.
Equipment to meet people’s changing needs was not always provided. The provider had not ensured appropriate equipment, such as profiling beds or pressure-relieving mattresses, were in place for people as and when they required them. This meant people may not have received care that met their needs safely or effectively.
Systems to ensure access to the service and communication with others were not reliable. During the assessment, inspectors made multiple attempts to contact the service by telephone; however, calls were not answered. This raised concerns that relatives and professionals may also experience difficulty contacting the service to obtain updates or information.
These concerns demonstrated the provider had not taken sufficient action to ensure all people could access care and support on an equal basis, and that barriers within the environment and systems had not been effectively addressed.
 

The provider did not ensure people experienced equitable care, treatment or outcomes. People living with dementia did not consistently receive the same quality of care, opportunities or support as those who were able to express their needs or make their own choices.
We observed people who were unable to communicate their needs or preferences were less likely to have their assessed needs met. For example, care plans identified some people required support with personal care, including bathing and showering, at regular intervals. However, we did not see evidence these needs were consistently met for people who were unable to request this support themselves. This placed them at increased risk of poor hygiene, discomfort and loss of dignity.
Staff interactions were primarily task-focused and did not support equitable experiences. We observed limited meaningful engagement with people living with dementia, particularly in communal areas where individuals remained disengaged for long periods. Staff did not proactively engage people in conversation, activities or reassurance, which meant those with cognitive impairments experienced poorer social interaction and stimulation.
People with cognitive or communication needs were not consistently supported to express their views or make choices. This meant decisions about their care and day-to-day experiences were often made without their active involvement, further widening inequity between people who could communicate their preferences and those who could not.
There was no evidence the provider had identified or addressed these inequalities in care delivery. Systems were not in place to monitor the experiences of different groups of people or ensure everyone received fair and person-centred care.
The provider had failed to ensure equitable experiences and outcomes, resulting in people living with dementia experiencing poorer care and reduced quality of life.
 

The provider did not ensure people’s current and future needs were effectively planned for. Care plans were not accurate, up to date or reflective of people’s changing conditions, which meant staff did not have reliable guidance to deliver appropriate care.
For example, 1 person receiving end of life care had a recently reviewed care plan which continued to describe them as independent. This did not reflect their significantly deteriorated condition or the level of care they required. There was no clear information outlining the person’s end of life needs, wishes or preferences, meaning staff did not have guidance on how to support them in a dignified, person-centred way.
Systems to ensure continuity of care were not effective. A one-to-one care worker had been arranged for this person from an external stakeholder; however, they had not been provided with a care plan or any background information. This meant they were unable to understand the person’s needs, preferences or history, placing the person at risk of not receiving appropriate care during a critical period.
End of life planning was not robust. Although some Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms were present within the service, these had not all been completed appropriately. In particular, the DNACPR form for the person receiving end of life care was not completed therefore did not document their wishes. This meant there was no clear evidence that decisions had been made in line with the person’s preferences or best interests.
The provider did not ensure staff had the necessary skills to meet people’s future needs. No training records were provided to demonstrate staff had received training in end-of-life care. Agency staff, including those leading shifts, also did not have evidence of end-of-life training. This meant we could not be assured staff had the knowledge or competence required to support people appropriately at the end of their lives.
The provider had not ensured effective planning for people’s future needs, including at the end of life, which placed people at risk of receiving care that was not safe, dignified or aligned with their wishes.