Elm Park 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 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. Analyses of accidents and incidents identified the number of accident and incidents and the cause, for example, pressure ulcers, safeguarding, falls or medication errors. The management team completed trend analyses and implemented actions to mitigate future risk. For example, following unwitnessed falls at night, there was an agreed action for night staff to remain on corridors to carry out observations and to monitor fall sensors in people’s rooms.

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. The electronic care planning system had the ability to generate hospital information reports when people attended hospital or other clinical services. The hospital information reports contained a summary of people’s care plans, risk assessments and care notes so continuity of care and support was maintained.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way for this to be achieved. 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 about safety quickly and appropriately. Clear safeguarding processes were in place and key information about how to report concerns about care and support were displayed throughout the care environment. Safeguarding concerns were identified in incident records, and we saw evidence detailed referrals were made to the local authority. People’s capacity was reviewed and assessed in line with the Mental Capacity Act 2005. Outcomes from capacity assessments were recorded in people’s care plans. A person told us, “It is brilliant here. I do feel safe; the staff make sure you are safe.” A family member said, “100% [family members] are safe here. I’m going away and I don’t know if I’d be able to go if [family members] had not settled here.” A member of staff told us, “I keep people safe by following all policies and procedures, making regular checks on people. I make sure care plans are followed, and all risk assessment recommendations are adhered to.”

We saw evidence the provider followed the principles of the Mental Capacity Act 2005 (MCA) to review people’s capacity and understanding around receiving care and support. The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. The registered manager oversaw DoLS documentation, and a spreadsheet was reviewed every month to monitor applications, approvals and expiry dates.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. People’s care needs were risk assessed and person-centred and detailed care plans developed. There were clear risk assessments and processes in place where people needed specific support for moving and handling. People’s care was delivered in line with their care plans and daily notes reflected care provided and action taken. A member of staff told us, “I often read people’s care plans at the start of my shifts and any time there are updates.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The care environment was well-maintained, and environmental risks were monitored and managed safely. Regular safety checks on equipment were completed in line with current legislation and regulatory requirements. The provider completed regular checks and reviews on key services including water temperature and hygiene, gas safety and fire protection.

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 which met people’s individual needs. Members of staff were deployed effectively throughout the care home, so people had access to care and support in a timely manner. Members of staff were recruited safely and received both online and face to face training to enable them to fulfil their role. The management team had oversight of the staff training information and there was a traffic light system which highlighted when refresher training sessions were required. There was a comprehensive system of supervision sessions for members of staff along with annual appraisals which ensured staff performance, competence and well-being were regularly monitored and reviewed. A family member said, “From what I can see there are enough staff. The staff are skilled; the training here is far more in depth than I’ve seen before. Staff have to do [some] courses off-site; they also do some training with the [Local Authority].”

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 care environment was clean and well-maintained. Personal protective equipment (PPE) was available throughout the care home. Members of staff wore PPE appropriately. A recent external clinical review of infection prevention and control (IPC) processes in the care home did not identify any concerns and confirmed the provider was compliant with local IPC expectations and clinical practice. A member of staff told us, “We have access to gloves, aprons and masks at all times.”

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Administration of medicines was managed safely. Systems and processes were in place to monitor, review and audit how people received their medicines. Clear protocols were in place for the administration of ‘as and when’ medications. One person told us, “I get my medication on time. Staff come in and put the [pain relief] patch on me. I have it [once a week].”