We carried out a review of the data available to us about Elm Park Care Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Elm Park Care Home, you can give feedback on this service.
Elm Park is a purpose built care home on the outskirts of Doncaster. The home provides accommodation for up to 100 people. At the time of our inspection there were 90 people using the service. The home provides residential and nursing care; this includes a dedicated unit on the first floor for people living with dementia.
People’s experience of using this service and what we found
Systems in place to monitor the service were not always effective. Audits in place had not always identified the concerns we initially found on inspection. Although concerns raised were swiftly addressed, new systems and approaches required embedding in to practice.
The management team and staff knew their roles and responsibilities. People and their relatives were complimentary about the home. The provider and registered manager used feedback to improve the service.
On the first day of inspection we found some areas of the home were in need of a deep clean. On the second day of inspection we found the service was clean and tidy. Appropriate action had been swiftly taken by the registered manager, who could demonstrate systems had been put in place to keep the home clean and well maintained.
The provider had systems in place to ensure people received their medications as prescribed. Some minor issues identified on the first day of our inspection were swiftly addressed by the registered manager.
The provider had a dependency tool which was used to identify the number of staff required each day. We found there were enough staff available to meet people’s needs in a timely way. The provider had a safe recruitment procedure to ensure appropriate staff were employed.
Accidents and incidents were recorded and analysed to identify any trends or patterns. This helped to mitigate future risks and ensured lessons were learnt. Risks associated with people's care had been identified and plans were in place to mitigate risks.
Staff were knowledgeable about safeguarding and confirmed they had received training in this subject. They knew what actions to take if they suspected abuse.
People's needs were assessed, and care was delivered in line with current legislation. We observed care and support being delivered in line with people's assessed needs and choices.
People were supported to maintain a healthy and balanced diet. We observed lunch being served and found people were assisted with making choices about what to eat. Through our observations, and speaking with staff, we found they had the skills to carry out their role. We found people had been referred to appropriate professionals when required, to ensure their needs were met.
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.
We observed staff interacting with people and found they were kind, caring and delivered support in a person-centred way. Relatives told us they were happy with the care their family member received and felt they were treated with dignity and respect.
Care plans were person centred and offered staff guidance about how to support people. Staff knew people well and assisted people to maintain their independence. Social activities were provided in line with people's interests and preferences.
Relatives we spoke with found the registered manager approachable and felt she would act on any complaints raised.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 04 November 2019 and this is the first rated inspection. We also carried out an inspection looking at infection control. This inspection report was published on 26 November 2020, but the service was not rated at this time.
Why we inspected
We carried out this inspection in line with our current methodology.
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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Elm Park 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.
We found the following examples of good practice.
The service had a visitor's information file located in the main reception area of the home. This contained useful information about safe visiting during the pandemic including the visitor's policy, infection prevention and control procedure, donning and doffing information, handwashing and correct wearing of face masks.
The service was accessing the government testing scheme, and this had helped them to identify the outbreak and take action quickly and efficiently. The service was managing the outbreak effectively.
The current admission policy was discussed where people are required to test negative for COVID-19 directly prior to admission and then isolate in their bedrooms for 14 days in order to assess for the development of any symptoms. After this period, people were tested in accordance with monthly testing arrangements.
During our inspection we saw staff washing and sanitising their hands frequently and using appropriate PPE in line with government guidelines. Staff also ensured they cleaned high touch points such as door handles and keypads, on a regular basis. Staff we spoke with had a good understanding of infection control procedures and were up to date with guidelines in place regarding appropriate use of PPE.
The service had a housekeeper who was responsible for ensuring the deployment of staff and cleaning schedules were completed in accordance with requirements, in addition the house keeper supervised staff in relation to IPC and COVID-19 requirements.
Further information is in the detailed findings below.