We carried out a review of the data available to us about Elm Lodge 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 Lodge, you can give feedback on this service.
Elm Lodge is a 'care home' with nursing. The service is registered to support up to 75 older people, some who may be living with dementia. At the time of the inspection 69 people were living at the service. The London Borough of Ealing funded or partly funded all the people who lived at the service. This is because they have a contract for the places there.
The home is divided into 5 units. Each unit can accommodate up to 15 people. The units have their own communal lounges and dining rooms.
People’s experience of using this service and what we found
We identified some medicines practices where improvements were needed. We also identified a small number of health and safety hazards. We discussed these with the registered manager and staff. They assured us about the action they had taken to make the improvements and to help prevent a repeat of these incidents. There was no indication people were harmed and we were satisfied the provider's action had improved the quality and safety of the service.
People told us they were well cared for and supported. They liked the staff and felt their needs were met.
The staff had assessed the risks to people's safety and had created plans to describe how they should be cared for. People felt able to contribute their views and were listened to.
There were suitable systems for dealing with accidents, incidents, complaints and learning when things went wrong.
There were a range of suitable audits which helped to ensure the quality of the service was monitored and improved.
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 and update
The last rating for this service was requires improvement (published 19 January 2022).
The provider completed an action plan after the last inspection to show what they would do and by when to improve.
At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
We carried out an unannounced comprehensive inspection of this service on 8 December 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.
For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) 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.
Elm Lodge is a 'care home'. The service is registered to support up to 75 older people, some who may be living with dementia. At the time of the inspection 64 people were living at the service. The London Borough of Ealing funded or partly funded all the people who lived at the service. This is because they have a contract for the places there.
In March 2020 the provider of the service changed to an organisation called Minster Care Management Limited. The management of the service, the people who lived there and staff remained the same.
People’s experience of using this service and what we found
People were generally happy with their care, but risks to their safety and well-being while being assessed were not always monitored or managed.
There were systems in place for monitoring the quality of the service and making improvements. These had not always been effective as they had not enabled the provider to take timely action to address some of the areas for improvement we found.
There were enough staff to meet their needs safely. The staff felt they were supported well. They received an induction, training and supervision in their roles. Recruitment processes made sure staff were suitable.
People were supported by staff who knew their care needs and preferences. Staff supported people with their food and drinks and to engage in a variety of activities on offer. The service worked in partnership with other agencies to support people's health needs. People received their medicines as prescribed.
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.
There were systems in place to safeguard people from the risk of abuse, investigate complaints and to address issues when things went wrong.
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 10 March 2020 and this is the first inspection. The last rating for the service under the previous provider was good, published on 9 October 2018.
Why we inspected
We inspected this service in line with our inspection methodology based on the date of registration.
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.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to safe care and treatment and good governance at this inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.