Elm Bank 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 requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 53 (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 always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

The service had processes in place for investigating, analysing, and responding to accidents, incidents, complaints, and safeguarding alerts. Lessons learned were shared with staff, for example, when concerns were raised about plates being too hot, this was discussed during stand-up meetings. However, the issue persisted the following day, indicating that learning was not consistently embedded into practice.

Staff and management worked collaboratively with healthcare professionals such as district nurses, doctors, and social workers, which supported the delivery of appropriate care. People using the service and their relatives had various ways to raise concerns or share their views, contributing to a culture of openness.

While there were systems to support learning and improvement, further work is needed to ensure that feedback leads to sustained changes in practice and that lessons learned are consistently applied to improve outcomes for people.

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.

Managers and staff mainly demonstrated awareness of individuals’ needs and associated risks. They provided tailored support to promote safety and wellbeing. For instance, when individuals had outpatient appointments, staff ensured that relevant information was shared. This helped external professionals understand the person’s needs and provide appropriate care. People told us the transition to the home was good. One person told us: "We visited Elm Bank before Person moved there. Person came to visit them, and they had moved within 24 hours, so the transition was very good. They had a great deal of support in settling in and is very happy there" Another said: “The home assessed Person when they were in hospital and accepted them, but the hospital went and discharged Person to the home without them or me being aware that Person was arriving there. They were very good though with settling Person down when they arrived, and very supportive. I think they were very good from that point of view."

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. 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.

Management worked closely with the local safeguarding team and responded appropriately when concerns were raised. Following any incidents, people’s health and wellbeing were closely monitored to ensure their safety and recovery. Where required, individuals had Deprivation of Liberty Safeguards (DoLS) in place, and all conditions were met in accordance with legal requirements.

Staff received safeguarding training and were able to give examples of when they had raised concerns, demonstrating awareness and confidence in safeguarding procedures. People using the service reported feeling safe. One person shared,“I am much safer here with staff and somebody always here to help.”

Policies were in place to support safeguarding practice. However, not all staff knew how to access these policies, which may limit their ability to refer to guidance when needed.

The provider did not work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans and risk assessments were in place and contained detailed instructions and best practice guidance for staff, such as how often to empty a person’s catheter and signs to monitor. However, in practice, these were not consistently followed. For example, one person’s records indicated their catheter should be checked and emptied every four hours, yet monitoring charts did not evidence this was taking place.

Monitoring charts for repositioning, food and fluid intake, and personal hygiene were not fully completed. This placed individuals at risk of developing pressure ulcers, dehydration, and poor hygiene outcomes. In one case, a person who was non-verbal and assessed as lacking capacity had not had their hair washed for 17 days with no reason being recorded. When questioned about the lack of oral care, a staff member responded that the person “has no teeth,” demonstrating a lack of understanding that oral care remains essential to prevent and identify conditions such as thrush and infections.

Concerns were raised with the management team during the on-site assessment. Management acknowledged the issues and advised that a new electronic recording system was being implemented, with staff scheduled to receive additional training to improve compliance and accuracy.

Staff had received training in areas such as moving and handling and health and safety.

Personal emergency evacuation plans (PEEPs)were in place. These plans were only accessible to staff via their electronic care system and not readily available to emergency services, which could delay or hinder safe evacuation during an incident. Management advised that, if required, emergency services could access these via a sister home, which may not be a reliable or timely solution.

Inconsistent implementation and oversight of risk management processes indicated people were at risk of harm or had experienced harm, and did not demonstrate safe or person-centred care.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

People and their relatives were complimentary about the décor, equipment, and overall environment. The refurbished flooring received praise. The home appeared clean, with good lighting, clear signage, and was mostly free of odours and hazards, enabling safe movement throughout. Wardrobes were secure in residents’ rooms, supporting personal safety and dignity. However, some areas appeared worn, and exposed wood on handrails was identified as a potential risk for skin tears. This issue was addressed during the assessment. Some electrical equipment was found to be untested within the required timeframe. While some items were removed immediately, full checks were completed during the assessment.

During this assessment we found no evidence of routine checks or oversight in place to monitor air mattresses. This was raised this with the management team who implemented a system for regular monitoring within their new electronic care planning system which would require time to be fully embedded.

Staff were observed serving hot plates to people using tea-towels, posing a risk of burns. Despite assurances from management, the issue was repeated on the second day of the visit. Management responded by stating that bain-maries now had temperature locks and that hot plates would be removed before entering the dining area.

The provider had continuity plans in place for emergencies such as power loss, fire, and other critical events.

The kitchen had a control of substances hazardous to health COSHH risk assessment folder, but it was outdated, listing staff who no longer worked at the care home and omitting a current staff member, this meant we could not be assured all staff had received full information about the substances within the kitchen environment, increasing the risk of accidents or exposure. This was updated during the assessment. Legionella testing was in date, but water checks in people’s rooms were inconsistent, with some not completed for 9 months, contrary to the provider’s quarterly policy. Additionally, appropriate actions were not recorded when temperatures were too high.

These findings indicate that whilst the environment was generally safe and well-maintained, there were areas requiring more consistent oversight and timely action to ensure safety standards were upheld.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

People and their relatives generally told us there were enough staff available to meet their needs. One person commented, "A lot of the staff there have been there for a long time. On Person's floor they have got consistency, and they are very much the same faces. Sometimes, they are short, and my relative has commented on that. I can't pinpoint the exact time when that might be the case." Another told us "Person does have to wait a few minutes, but I think that is normal. I think there appears to be enough. Sometimes, you might think there are not enough but that is possibly because they are attending to another resident."

Staffing levels were consistent with the published rotas, and additional support was provided by staff from sister homes within the Barchester group when needed.

New staff were mainly recruited safely. However, we identified some gaps in the recruitment process, which were not in line with their employee handbook. This was shared this with the management team. This was put in place during the assessment.

Staff mainly received training tailored to meet people’s specific needs. Despite this, we found that not all staff supporting individuals with catheters had received the appropriate training. This was fed back to the management team, who assured us that this would be addressed promptly.

Staff competencies were assessed and reviewed periodically. In addition, staff received supervision and regular feedback on their performance.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The home appeared clean throughout, including corridors, dining areas, bedrooms, and bathrooms. All bathrooms had hand wash and paper towels. One relative told us, "This is my first visit and its clean and looking good." However, on the first day of our assessment visit, we observed that some wheelchairs were found to be inadequately cleaned, and a soiled sling was observed being reused between morning and lunchtime. Both issues were raised with the management team and addressed promptly. A damaged bed bumper was also identified by inspectors and promptly replaced by the provider. This demonstrated management oversight needed to improve to ensure such instances were identified through the management checks.

Daily records of food and fridge temperatures were maintained. However, one fridge was repeatedly recorded as too warm. Although the chef had been informed, no further action had been documented. This was escalated to the management team who advised a new process was put in place.

Food was generally stored hygienically, with items labelled and mostly within date. However, out-of-date burger was found in one fridge in the serving kitchenettes, biscuits were left uncovered in a cupboard and bread was found on both days of the visit and brought to management’s attention. Additionally, the oven and shelving above the cooker were in need of cleaning, as were the serving trolleys. These issues were addressed immediately once identified.

Staff had received infection prevention and control training, and good practice was observed. PPE was readily available, however some staff reported carrying extra gloves in their pockets.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Concerns had been raised regarding the safe administration of medicines prior to the onsite visit.

During our assessment staff were observed administering medicines safely and engaging with people throughout the process.

A safe medicines administration and recording system was in place.

Most care plans included guidance for administering ‘as required’ (PRN) medicines. However, we saw evidence of a person's PRN not being used when required this meant the person's medical needs were not met. One person who had prescribed medicine which did not have a PRN protocol in place. This was highlighted to the management team, and a protocol was subsequently implemented.

In cases where PRN medicines were used frequently, there was not always evidence of GP review. This demonstrated staff were not always following their own procedure and seeking medical advice. This was brought to the attention of management.

Food and drink thickeners were found in unlocked cupboards, posing a potential risk. This was addressed with the management team during the visit.

One thickener had been opened but was not dated. Staff were informed, and the item was updated accordingly.

Sprays were found without opening dates being recorded, making it unclear whether they were safe to use. This was raised with the care team, and the items were removed and replaced immediately.