Elmhurst Intermediate Care Centre

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them with advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.
This is the first inspection for this service since its registration with CQC.
This key question has been rated as Good.
 

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 service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

People were admitted once medically fit and received care that was focused on rehabilitation, maximising independence and supporting a return to their home environment wherever possible.

Care records and personalised treatment plans were completed following admission and were reviewed regularly to reflect identified needs and progress towards rehabilitation goals. Staff consistently used clinical and risk assessment tools effectively, including nutritional assessments and the National Early Warning Score (NEWS2) to support the early recognition and escalation of deterioration. Our review of records and found NEWS2 scores were completed accurately and in a timely manner.

We observed ward rounds where multidisciplinary team (MDT) members reviewed people’s progress collaboratively, discussed treatment options and involved people in decisions about their care. Daily nursing handovers included discussions of risks and changing needs, with care plans updated and onward referrals made where required. Managers were able to implement enhanced observations when necessary to maintain people’s safety.

Care records demonstrated that nutritional and hydration needs were assessed and monitored appropriately using food and fluid charts. We saw evidence that staff assessed, monitored and responded to people’s physical, psychological and rehabilitation needs, ensuring care remained effective and personalised throughout their stay.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff understood their responsibilities under the Mental Capacity Act 2005 and associated Code of Practice. Although there were no people subject to the Act at the time of inspection, staff were able to explain how they would assess capacity, support decision-making and act in people’s best interests where required.

Staff used nationally recognised assessment and screening tools to support safe clinical decision-making. These included NEWS2 scoring to identify and respond to deterioration, the Malnutrition Universal Screening Tool (MUST), falls risk assessments and pain assessment tools.

People were involved in setting rehabilitation goals and reviewing their progress, with care plans tailored to meet their individual physical, emotional and social needs.

Systems were in place to ensure staff had access to current guidance, policies and best practice. Key clinical information and assessment tools were readily available to support consistent care delivery. Records we reviewed demonstrated that care and treatment were planned, delivered and evaluated in line with current evidence-based guidance.

We observed effective multidisciplinary working, with nursing, therapy and medical staff collaborating to review people’s progress and adjust treatment plans where required. Rehabilitation and therapy interventions were focused on maximising independence and supporting people to return home safely wherever possible.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

We observed a strong culture of collaboration, with excellent communication and coordination evident across all roles and disciplines. Staff spoke highly of the supportive team environment and demonstrated a shared commitment to delivering safe, effective and person-centred care. Information was communicated in a timely manner, ensuring people’s changing needs were understood and responded to appropriately.

Daily multidisciplinary team (MDT) meetings, which inspectors attended during the assessment, decision-making, proactive discharge planning and regular review of people’s progress. Discharge planning began at the point of admission and remained a focus throughout the rehabilitation pathway, ensuring people and staff worked towards clearly defined goals that maximised recovery and independence.

MDT discussions were comprehensive and person-centred, considering mobility, therapy needs, personal care requirements and ongoing social care support. Occupational therapists, physiotherapists, nursing staff and other healthcare professionals worked exceptionally well together to coordinate care, secure appropriate community services and arrange tailored packages of support. This proactive and integrated approach enabled timely, safe discharges and helped people achieve the best possible outcomes.

Attendance at handovers, nurse safety huddles and ward rounds varied appropriately according to people’s needs, ensuring relevant professionals were involved in decision-making. Multidisciplinary input included medical staff, advanced clinical practitioners, nurses, healthcare support workers, physiotherapists and occupational therapists.

We observed open and constructive communication during ward rounds, safety huddles and handovers. Staff worked collaboratively to manage risks, respond promptly to changing needs and support effective rehabilitation.

The service worked exceptionally well with partner organisations, including acute hospitals, bed management teams, community services and specialist therapy teams, to coordinate admissions, transfers and discharges. Information was shared effectively between services to support seamless transitions of care and ensure people experienced a coordinated approach throughout their rehabilitation journey.

People who had previously used the service spoke positively about the support they received from admission through to discharge home. Feedback highlighted good continuity of care, effective communication between services and a coordinated approach to rehabilitation and recovery.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. Care and rehabilitation were focused on helping people regain confidence, improve their functional abilities and achieve goals that would support a safe return home.

Staff promoted healthy lifestyles and provided practical advice to encourage recovery and independence. People were involved in setting rehabilitation goals and encouraged to participate in therapy and daily living activities to maximise their independence and reduce future care needs where possible.

Physiotherapy staff focused on preventing deconditioning by promoting mobility, exercise and independence throughout a person’s stay. The multidisciplinary team (MDT) worked together to support people’s physical, emotional and social wellbeing and developed personalised plans to support recovery and ongoing self-management.

Staff provided education and support to help people understand their health conditions, medicines and ongoing care needs. We observed a range of patient information materials, including leaflets, posters and display boards, which promoted healthy living, supported discharge planning and signposted people to local and national support services and charities.

Discharge planning commenced on admission, with staff working closely with community and partner services to ensure appropriate support was in place to help people maintain their health, wellbeing and independence after leaving the service.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Leaders monitored outcomes to ensure care met clinical expectations and the needs of people using the service. Outcomes reflected the service’s focus on rehabilitation, maximising independence and supporting people to return home safely wherever possible.

Managers and staff used a range of information, including audit findings, incident data and feedback from people using the service, to identify opportunities for learning and improvement. Clinical records we reviewed demonstrated that people’s experienced positive outcomes and received care in line with legislation, national standards and evidence-based guidance.

The service participated in relevant national audits and completed a programme of local clinical audits covering areas such as safeguarding, medicines management, infection prevention and control, and hand hygiene. Managers used the findings from these audits to monitor performance and improve care and treatment.

Managers undertook regular clinical and environmental audits, with clear oversight of actions, identified leads and monitoring of progress. Quality and safety were reviewed through governance meetings, quality boards and staff meetings. We saw evidence that learning from audits, incidents and feedback was used to drive improvements in care delivery, safety and outcomes for people using the service.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

People were informed that they could change their minds and withdraw consent at any time, and staff respected these decisions. Consent was clearly documented within care records.

Staff supported people to make informed decisions about their care and treatment and followed national guidance when seeking consent. We observed positive shared decision-making, with staff routinely seeking verbal consent before examinations, treatments and personal care interventions. Staff communicated respectfully and adapted their approach to meet individual needs, including allowing additional time for discussions and providing information in ways people could understand.

Staff demonstrated a good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Where people lacked capacity to make specific decisions, staff acted in their best interests and considered their wishes, feelings, culture and personal history. Capacity assessments, best interest decisions and DoLS applications were completed appropriately and reviewed in line with national guidance.

Records we reviewed showed consent to care and treatment was documented appropriately. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were completed accurately and reviewed in accordance with relevant legislation and national guidance. The multidisciplinary team (MDT) routinely considered people’s capacity and decision-making needs to ensure care remained person-centred and respected rights and preferences.