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Archived: Elmsleigh Care Home Inadequate

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating


Updated 25 November 2016

Elmsleigh is a care home that provides nursing care for up to 48 older people, some of whom had a diagnosis of dementia or other mental health conditions. On the day of the inspection there were 45 people living at Elmsleigh. Thirty-three people lived in the main house and 12 people lived in the adjoining annex (called the bungalow).

The service is required to have a registered manager and at the time of our inspection a registered manager was not in post. The manager who was in charge of the day-to-day running of the service had applied to become the registered manager. At the time of this inspection their application was being processed. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

We carried out this unannounced inspection of Elmsleigh Care Home on 25 October 2016. At this comprehensive inspection we checked to see if the service had made the required improvements identified at the inspection of 14 June 2016.

In June 2016 we found the premises and equipment were not properly maintained. There were two shower rooms, where the showers had been removed, and the floors were stained and dirty. There were three bathrooms that were not in full working order, including water that was too hot to be safely used by people living at the service. An unlocked boiler room, accessed through a bathroom, put people at risk of harm because the room had hot pipes and electrical equipment. There was broken equipment stored around the premises, including in areas identified at a previous inspection in September 2015.

At this inspection while we found some improvements had been made to the premises and the environment there were still areas of concern. There were communal bathrooms and en-suite bathrooms that either did not have hot water or had water that was too hot with the risk of scalding people. One shower room had a wall mounted electric bar heater approximately three feet immediately opposite the shower which meant water could come in contact with the heater. There was no hot water available in the kitchen on the day of the inspection. While the door to the boiler room, accessed through a communal bathroom, was locked the door leading into the boiler room in a corridor was not locked. Three bedroom self closing fire doors were seen wedged open by furniture and a suitcase in one case. These issues put people at risk of harm.

Most of the broken equipment that had previously been stored around the building had been removed. However, we did find an unused pressure mattress, unnamed continence pads and a ladder stored in the entrance area to a toilet used by people. The premises were warm throughout the inspection, except for one corridor which was cooler than the rest of the building. The communal areas were clean and odour free. However, some people’s bedrooms were not clean and had strong incontinence odours. Several toilets and bathrooms did not have paper towels, soap or waste bins to enable effective hand washing and infection control. All of the above created an environment that was not homely or pleasing for people to live in.

In June 2016 we had concerns about the safety of two people living at the service who had been assessed as being at high risk of falls and ‘unsafe if left unobserved’. At this inspection we found action had been taken to help reduce the risk of harm for these two people. One person’s health had deteriorated and they were less mobile than they had been. They had also been provided with head protection, to protect their head if they did fall. The other person had been given funding to have individual care. While this had helped to reduce their falls this person could still suddenly get up and attempt to walk. However, there was no risk assessm

Inspection areas



Updated 25 November 2016

The service was not safe. The premises and equipment were not properly maintained.

People were not always protected the from risk of harm because risks were not always identified and managed. Pressure mattresses were not correctly set putting people at risk of skin damage. Medicines were not safely managed.

The numbers of staff on duty was often lower than the level assessed as needed to meet people�s needs.


Requires improvement

Updated 25 November 2016

The service was not effective. Some people did not receive care and treatment that met their needs. The service had not sufficiently identified the risks to people with complex needs in relation to eating and drinking.

Some people�s individual rooms were not clean and had strong incontinence odours.

Permanent staff had the knowledge and skills to meet people�s needs. Bank staff didn�t always have enough knowledge about people to meet their needs.

Management did not have a clear understanding of the legal requirements of the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards.


Requires improvement

Updated 25 November 2016

The service was not entirely caring. Staff were kind and compassionate when they spoke with people. However, some staff completed tasks for people with little conversation.

Staff had not been given sufficient guidance or support in how to communicate with people with complex needs.

People�s privacy and dignity was not respected because slings, net pants and continence pads were shared between people.

Care plans detailed people�s choices and preferences about their care and support.



Updated 25 November 2016

The service was not responsive. People did not receive care and treatment that was responsive to their individual needs. The care provided to people was often task orientated rather than in response to each person�s individual needs

Care plans were not personalised to reflect people�s care and treatment needs. Care plans were not updated as people�s needs changed.

There was a lack of meaningful activities to meet people�s social and emotional needs.



Updated 25 November 2016

The service was not well-led. The provider had not adequately assessed, monitored and mitigated the risks to people living in the service.

Some people did not receive consistent or good care because systems to provide and monitor people�s needs were inadequate.

Audit processes were not effective as these had failed to identify shortfalls in relation to the premises, medicines, care plans and the monitoring of people�s health and care needs.