Elm Lea 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 remained good.

This meant people were safe and protected from avoidable harm.

This service scored 75 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There were systems and processes in place to ensure that when something went wrong, it was documented and lessons were learnt. Staff knew how to identify and report accidents and incidents. Staff also reported near misses, for example when a person coughed when they ate food, so that actions could be taken to reduce future risks of potential choking.

The registered manager reviewed incidents and had created a training checklist which was updated and shared with staff. Where necessary, staff were supported to access refresher training to support their learning when needed.

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.

When people moved between services, the provider ensured relevant information was documented and moved with them, such as hospital passports. A hospital passport is a personal document that contains information about an individual's health, communication preferences, and personal needs to help professionals provide consistent care. Staff were aware of people’s preferences and when they had ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) forms in place. A ReSPECT form is a written medical document that records a person's personal preferences and clinical recommendations for future emergency care.

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.

Staff had a good understanding of safeguarding concerns, and how and where to escalate concerns to. A staff member told us, “I would record the concern, make sure the resident is safe. I would report to my manager straight away and we would follow the safeguarding policy of the home.” Safeguarding concerns had been logged by the registered manager, investigated and reported to the local authority safeguarding team.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that the registered manager complied with DoLS legislation and people were not restricted unlawfully.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Some people were at risk of choking and had choked. Following these instances we found the registered manager had supported staff to update their health and safety training, and all guidance for people at risk of choking had been updated and shared with staff. The registered manager had checked staff knowledge, and ensured that appropriate referrals were made to the speech and language team (SaLT).

Risks to people had been assessed and comprehensive compressive guidance and risk assessments were in place. People’s health needs had been assessed, and people living with unstable health conditions such as diabetes were supported well. One person’s loved one told us that since moving into the service their loved one had been supported to reduce their blood sugar levels which were previously very high to a normal level with the support of regular medication and a good diet. High blood sugar levels can damage blood vessels and organs over time, leading to severe health complications.

Other people’s health conditions were also well managed. For example, when people were cared for in bed, staff ensured they were supported to re-position regularly to avoid the risk of skin breakdown. People’s care plans and risk assessments provided guidance for staff to follow to reduce risks to people, and they had been updated frequently. People and their relatives told us their loved ones were safe. They told us, “In terms of my dad I've never questioned if he is safe and if they take the right steps to support him,” and, “Absolutely he is safe there.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Checks had been carried out on the environment to make sure it was safe for people. This included ensuring that equipment was in good working order, including lifts, hoists and equipment to be used in the event of a fire.

The service was homely with people’s rooms being uniquely personalised to show their likes interests. A relative told us, “They make it as homelike and friendly as possible. I appreciate that.” The registered manager had ensured people’s doors were personalised to help them orientate themselves. One person’s room had a picture of an animal on the door which was the nickname their family fondly referred to about them.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The registered manager reviewed staffing levels regularly using a dependency tool, and observations. A dependency tool is a system used to assess resident needs, calculate required staffing levels. People and their loved ones told us they felt there was enough staff. They told us, “I think there's enough staff. They have got it well sussed,” and “I don’t think they are short staffed as if something happens lots of staff appear.”

Staff had received training and supervision to enable them to support people safely. Staff understood people’s health need and how to support them safely. This included complex health conditions such as diabetes, and how to support and calm people when they became distressed. Relatives told us, “There are staff there that I think are great. They really do understand my dad and how to manage him the best,” and “No concerns at all about the staff, they are excellent.” Staff were recruited following safe recruitment processes.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean and free from any malodours. There were sufficient ancillary staff to ensure the service was clean. People and their relatives told us that the service was clean. They told us, “It’s absolutely clean, it’s spotless,” and “It’s always clean and tidy, her bed is always nicely made.”

We observed staff wearing appropriate personal protective equipment (PPE) when they were providing care and communal areas were clean and well maintained.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were stored and administered safely in ways that met people’s needs. We reviewed Medicine Administration Records (MAR) and found they had been completed fully, providing assurance that medicines had been administered as prescribed. Staff were knowledgeable about medicines and their responsibilities in administering them including any protocols in place. Some people were prescribed medicines on an ‘as and when’ basis. We found there were protocols in place to inform staff when to administer them. We found that mood altering medication had not been over administered.

A relative told us, “They give me a detailed report about what medicine he is on and why he is taking them. It’s all written down and I can refer to it.”