Elm Lodge Residential Care Home

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 changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of legal regulation in relation to people’s safe care and treatment, the ways people’s medicines were managed, safeguarding of vulnerable people, safe environments, safe staffing, recruitment processes and failure to notify.
 

This service scored 25 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.
Staff did not consistently recognise, report, or learn from accidents and incidents. Where incidents were recorded, there was no evidence of effective follow-up action to reduce the risk of recurrence. For example, 1 person experienced multiple falls; however, their risk assessments had not been updated to guide staff on appropriate measures to reduce further risk. This indicated that learning from incidents was not embedded in practice and placed people at continued risk of harm.
In addition, systems to review and analyse incidents were not effective. Although some incidents for April 2026 had been recorded, there was no analysis of trends, themes, or the effectiveness of responses, and no evidence of shared learning. This limited opportunities for improvement and demonstrated a weak learning culture within the service.
 

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services
The provider did not ensure robust pre-admission assessments were consistently completed prior to people moving into the service. Information shared by other healthcare professionals was not always fully captured or reflected in people’s care plans. This meant care records did not demonstrate clear continuity of care or accurately reflect people’s needs, preferences and wishes.
Some admissions were completed without sufficient consideration of the impact on people already living at the service. This included changes to bedroom arrangements, which were made without due regard to the needs and wellbeing of those affected.
Systems to support safe transitions between services were not effective. When people were admitted to hospital, staff did not always provide up-to-date or relevant information to healthcare professionals, which could compromise people’s safety and continuity of care.
 

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.
The provider did not have effective systems and processes in place to recognise and respond to safeguarding concerns. There was a lack of shared understanding among staff regarding what constituted a safeguarding referral and when concerns should be escalated.
One person had left the service without staff knowledge on 2 occasions, and another person had sustained a significant unexplained injury. These incidents had not been referred to the local safeguarding authority or notified to the Care Quality Commission, in line with the provider’s statutory responsibilities. This placed people at risk of harm and demonstrated a failure to protect people from potential abuse or neglect.
Where people were subject to Deprivation of Liberty Safeguards (DoLS), applications had been made to the local authority where appropriate. However, the provider did not consistently maintain accurate and up-to-date records in line with the authorisation conditions. For 1 person, the provider was unable to demonstrate how they were meeting the conditions of their DoLS authorisation, meaning there was no assurance restrictions were being applied lawfully or in the person’s best interests.
 

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
Risks to people were not safely assessed or managed. People were not consistently involved in the assessment and planning of how risks to their health, safety and wellbeing should be reduced. For example, 1 person had experienced 3 recent falls resulting in injury. Their falls and mobility risk assessments had not been reviewed or updated to reflect these incidents, which meant appropriate measures were not in place to reduce the risk of further harm. Another person had sustained skin damage; however, there were no risk assessments in place to guide staff on how to manage this risk and prevent further deterioration.
Although some risk assessments were in place, these were not consistently accurate, up to date, or reflective of people’s current needs and conditions. Reviews had not been effective in identifying changes in risk. Risk assessments lacked sufficient detail and did not provide clear guidance for staff on how to safely support people or mitigate identified risks. This placed people at ongoing risk of harm.
 

The provider failed to ensure the premises were safe and suitable for people living at the service. Environmental risks were not effectively identified or mitigated, placing people at significant risk of harm.
On the first day of the assessment, the service was unacceptably cold. One person told us, “I am freezing.” A portable heater had been placed nearby; however, this was hot to the touch and presented a risk of burns. The person attempted to touch the heater and was prevented from doing so by another person using the service. This demonstrated a lack of safe risk management. Following our feedback, the heater was removed.
The provider had not maintained appropriate heating or building infrastructure. Windows in communal areas did not close properly, resulting in significant drafts, and the central heating system was not in regular use, as confirmed by staff. When inspectors requested the heating be turned on, a strong smell of gas was identified. The emergency gas service attended, and the gas supply was shut off until the system could be made safe by a qualified engineer.
The provider did not maintain adequate records to demonstrate the safe servicing and maintenance of the premises or equipment. This meant we could not be assured that the environment or equipment used was safe.
Fire safety arrangements were not effective. There were gaps beneath fire doors, and some fire doors did not close independently, compromising their effectiveness in the event of a fire. There was no evidence of regular fire drills or testing. Personal Emergency Evacuation Plans (PEEPs) were not readily accessible, and staff were unaware of their location on the first day of inspection. When reviewed on the second day, PEEPs contained inconsistent and inaccurate information. Staff told us they had not participated in fire evacuation drills and were unclear about the procedures to follow in an emergency. This meant people could not be assured they would be safely supported to evacuate if required.
 

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.
The provider did not operate safe or effective recruitment processes. They were unable to demonstrate an understanding of the requirements for safe recruitment. For example, 1 member of staff was working at the service without the necessary pre-employment checks, including references and a Disclosure and Barring Service (DBS) check. This placed people at significant risk of harm.
The provider did not maintain oversight of staff training or competency. No training records or evidence of competency assessments were made available during the assessment. This meant we could not be assured staff had the necessary skills, knowledge or training to provide safe care and treatment. There was also no system in place to support staff through supervision or induction. New staff were not appropriately inducted and told us they did not have access to, and had not reviewed, people’s care plans prior to providing care.
Staffing deployment was not safe or effective and did not ensure people’s needs were consistently met. On both days of the assessment, 2 care staff and 1 senior staff member were responsible for a wide range of additional duties, including cleaning, preparing meals after kitchen staff had left, and completing laundry tasks due to the absence of dedicated domestic and laundry support. The senior staff member was also responsible for medication administration and administrative duties, with no management or clinical oversight available. This significantly reduced the time staff were able to spend meeting people’s care needs.
Staffing rotas were inconsistent and did not accurately reflect staff on duty. Records showed occasions where only 1 care staff member was scheduled or where staff listed on duty were not present, with no clear record of who was covering shifts. Despite these concerns being raised with the provider on the first day of inspection, no improvements were observed on the second day. This placed people at ongoing risk of unsafe or inadequate care.
 

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.
Systems to prevent and control the spread of infection were not effective. The environment was not always maintained to an acceptable standard of cleanliness, which increased the risk of cross-contamination.
The provider had only 1 part-time domestic staff member responsible for all cleaning tasks across the service. The staff member told us they did not have sufficient time to complete all required duties, including routine cleaning as well as enhanced and deep cleaning tasks. We saw evidence activities such as deep cleans, mattress and mattress cover cleaning were not being undertaken. This was not due to a lack of effort from the domestic staff member, who was working within their capacity, but due to insufficient staffing resources to meet the service’s needs.
We observed several areas within the service, including communal areas and bedrooms, that were visibly unclean. On day 2 of assessment, there was a significant malodour present in parts of the service, including some people’s bedrooms.
Waste management processes were not always followed. Clinical waste was not consistently disposed of appropriately, and some clinical waste bins did not contain liners, which posed an infection control risk.
Staff did not always follow best practice in relation to infection prevention and control. Some staff were not bare below the elbows and wore jewellery; however, we observed that appropriate personal protective equipment (PPE) was generally used.
Sufficient systems and resources were not in place to ensure consistently safe standards of cleanliness and hygiene.
 

Medicines were not managed safely. Systems for ordering, storing, administering and recording medicines were ineffective and placed people at risk of harm.
There were no reliable stock control systems in place. Running balances were not maintained, stock checks were not completed, and some people were at risk of running out of their medicines on the day of assessment. There were no clear processes to demonstrate how medicines were ordered and received.
Medicines were not always administered as prescribed. Some people did not receive their full prescribed doses, including medicines intended to be given multiple times a day and regular pain relief. For example, 1 person was prescribed Paracetamol to be given 4 times a day to manage pain, however staff had handwritten this on medication administration records (MARs) as an ‘as required’ (PRN) medication and failed to administer this.
Other PRN medicines were given without appropriate protocols, and records showed examples of medicines being administered incorrectly, including regular use of PRN medicines for behaviour support.
Recording practices were unsafe. Handwritten MAR charts were not subject to second checks, and administration records did not accurately reflect the times medicines were given. Time-critical medicines were not administered safely, with appropriate intervals between doses not maintained.
Governance around topical medicines was poor. There were no body maps to guide staff, and untrained staff were applying medicated creams. Records were inaccurately signed by staff who had not administered the medicines.
Medicines storage and monitoring were not safe. Temperature checks were not recorded for storage areas or fridges, and items such as creams and eye drops were not dated on opening. Controlled drugs records had not been appropriately maintained or reconciled, with historic entries remaining unaccounted for.
These concerns demonstrated a widespread failure to ensure the safe management of medicines.