Elm House Residential Care Home

Updated 24 March 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.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector.

Service and service type

Elm 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. Elm 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 not a registered manager in post. A new manager had been in post for one month and had submitted an application to register. We are currently assessing their application.

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. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We used all this information to plan our inspection.

During the inspection

We spoke with 5 people who used the service about their experience of the care provided. We spoke with 8 members of staff including the area manager, manager, care workers and ancillary staff. We reviewed a range of records. This included 5 people’s care records, risk assessments and medication records. We looked at 4 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We looked at various documents and continued to seek clarification from the provider to validate evidence.

Updated 24 March 2023

About the service

Elm House is a residential care home providing personal and nursing care to up to 39 people. The service provides support to older people. At the time of our inspection there were 30 people using the service. The service can accommodate people in one purpose-built building.

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

Identified shortcomings in the quality of care in recent months had been recognised and improvements had been achieved by a new management team. The team recognised that while many improvements had been made, further progress was needed. This view was also shared by relatives of people living at the service.

Medicines were not always safely stored. We found a flammable prescribed cream in one bedroom that was not safely stored. The manager informed us subsequent to the inspection that action had been taken to address this and that ordinarily, all other creams were appropriately stored and risk assessed. Audits had been carried out on medicines systems and more work to drive up standards had been recognised.

People living at Elm House were happy with the support they received. People felt safe and were complimentary of the staff approach to them which was said was kind and caring.

The building was well maintained although it was identified that future refurbishment would be needed.

The management team had been transparent with other agencies including CQC and had introduced improved audits and set up more regular contact with families. The staff team felt more included in the running of the service and felt that a more inclusive culture had been created.

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.

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

Rating at last inspection

The last rating for this service was good (published 20 February 2019).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Elm House on our website at www.cqc.org.uk.

Follow up

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