Elms House

Updated 28 July 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

This inspection was carried out by 1 inspector.

Service and service type

Elms House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Elms House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection

During the inspection we spoke with 1 person who resided at the service and 1 witness to the care people receive. We reviewed 1 person’s care plan and associated care documentation which included medicine records and plans for the future. We spoke with 8 staff members including the registered manager, team leaders, care staff and an agency worker. We also spoke to 2 professionals from the Mental Health Trust. We looked at audits carried out in the service alongside relevant policies and procedures.

Updated 28 July 2023

About the service

Elms House is a short-term residential care home providing personal care to up to a maximum of 14 people. The service provides rehabilitation support to adults with mental health needs. At the time of our inspection there were 13 people using the service.

The service is situated close to local amenities and has 11 bedrooms in the main house and 3 independent living flats. People have access to communal living space and a large garden.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

People’s experience of using this service and what we found

Governance systems were in place. However, the provider did not always have oversight of the landlord’s health and safety checks to ensure all the required areas were covered. Numerous in-house audits were completed but we found the actions identified were not always documented in an action plan which could be monitored.

Risks to people’s safety identified at the previous inspection had been mitigated and actions from the previous fire safety report had been completed. Infection prevention controls were safely managed.

People received their medicine on time from staff who had been trained in safe administration and a better process was in place for people needing to take their medicine out of the home.

People were supported by sufficient staff who had received appropriate training for their role and showed dedication to helping people achieve their outcomes. Staff worked closer with the mental health trust and plans were in place to increase the support and training they received.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Lessons were learnt when things went wrong and it was evident improvements had been made to several aspects of the service since our last visit. Roles and responsibilities were clearer, and the culture was positive.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (Published 16 November 2018). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was prompted by a review of the information we held about this service. It was agreed we would carry out a focused inspection to review an historic breach of regulation 12.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.