Elmhurst Intermediate Care Centre

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

We looked for evidence that people were protected from abuse and avoidable harm.

This is the first inspection for this service since its registration with CQC.

This key question has been rated as Good.

This service scored 72 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff told us they felt supported to raise concerns and were confident these would be listened to and acted upon. Effective processes for reporting, reviewing and investigating incidents were in place, with learning shared through team meetings and governance processes to support improvement.

The service demonstrated a commitment to continuous learning. Staff reviewed falls incidents and trends to develop strategies aimed at reducing falls and associated harm. Leaders and staff also evaluated changes to the unit environment and ways of working to identify opportunities to improve safety, support rehabilitation and enhance people’s outcomes.

Systems were in place to manage complaints and concerns. The service had not received any complaints in the 12 months prior to inspection. Staff told us they felt respected and supported by colleagues and leaders and described a culture where people were encouraged to speak up and contribute to service improvements.

We observed positive multidisciplinary team (MDT) working, with a shared focus on delivering safe and effective rehabilitation.

The service 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.

There were clear processes for managing referrals, admissions and discharges, ensuring people were admitted appropriately and experienced continuity of care throughout their rehabilitation.

People were assessed for suitability prior to admission and were medically fit before being transferred to the service. Staff worked closely with acute hospitals, community teams and social care partners to support safe transitions of care and timely discharge planning. Rehabilitation goals were established early and reviewed regularly by the MDT to support people in achieving the best possible outcomes.

Information was shared promptly between services, supporting coordinated care and reducing the risk of delays. We observed effective multidisciplinary working and communication, which helped ensure care was planned and delivered safely.

Staff told us discharge planning began on admission and involved people, families and partner agencies to support a safe return home wherever possible.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

There was a strong focus on protecting people from abuse, neglect, discrimination and avoidable harm while supporting their independence and rehabilitation goals.

The service had a Safeguarding Adults and a Safeguarding Children and Young People policies in place. Staff had access to these policies and demonstrated a good understanding of their safeguarding responsibilities.

Staff received safeguarding training appropriate to their role and knew how to recognise, respond to and escalate concerns. Safeguarding information was readily available, and staff were able to describe the processes for raising concerns.

Safeguarding concerns were shared promptly and appropriately with relevant agencies and partner organisations to help protect people and ensure their needs were met. Leaders monitored safeguarding activity through governance processes and used this information to identify themes and opportunities for learning and improvement.

Staff worked closely with people, families and partner agencies to promote safety and wellbeing while respecting people’s rights, dignity and independence.

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

People were involved in decisions about their care and supported to manage risks while working towards greater independence and discharge home.

Staff completed risk assessments for each person on admission using nationally recognised tools. For example, the National Early Warning Score (NEWS2) was used to identify people at risk of deterioration. Our review of records showed staff completed NEWS2 assessments accurately and responded appropriately to identified risks.

We reviewed a range of risk assessments, including those relating to falls, pressure ulcers, sepsis and nutrition. Where actions or care plans were required to mitigate identified risks, records showed these had been implemented and reviewed regularly.

The multidisciplinary team (MDT) worked collaboratively to monitor and manage risks, ensuring people received safe and effective care throughout their rehabilitation.

Emergency equipment was available and appropriately maintained. Staff were able to recognise and respond to deteriorating people and understood the actions required should their condition change.

Fire safety arrangements were in place, including evacuation equipment to support the safe movement of people during an emergency. This included evacuation chairs and foil blankets to help keep people warm and dry should an evacuation of the unit be required.

Staff worked to balance safety with the promotion of independence, enabling people to take positive risks where appropriate while ensuring measures were in place to minimise the risk of harm.

The service detected and controlled potential risks within the care environment and ensured that equipment, facilities and technology supported the delivery of safe care.

People were allocated individual rooms on admission based on their assessed needs, including mobility levels and falls risk. Those who required additional support or closer observation were generally accommodated on the ground floor, while those who were more independent were accommodated on the first floor. This enabled staff in providing care in an environment appropriate to people’s individual needs and risk levels.

People had access to a secure garden and patio area, which provided a safe and accessible environment for wellbeing activities and rehabilitation. The outdoor space was available to people, families and carers and included seating areas and landscaped gardens.

Staff had easy access to personal alarms, and people could access nurse call systems throughout the unit, enabling them to request assistance when needed. We observed that call bells were readily accessible.

Clinical areas were clean, organised and appropriately maintained. Clinic rooms were fully equipped with accessible resuscitation equipment and emergency medicines, which were checked regularly in line with local procedures. Staff carried out daily checks of specialist equipment to ensure it remained safe and ready for use.

Systems were in place to ensure the premises and equipment were maintained. Health and safety audits and risk assessments were undertaken, with actions taken to address identified risks. The service had arrangements to support business continuity and emergency preparedness to ensure safe care could continue during unforeseen events.

The service generally ensured there were enough staff to meet patients' needs. However, the provider did not consistently ensure staff completed all mandatory training requirements, which limited assurance sufficient staff had the knowledge and competencies required to support the delivery of safe care.

Staff worked effectively within a multidisciplinary team, and we observed positive joint working between clinical and non-clinical staff throughout the assessment.

The workforce included nurses, healthcare support workers, therapists, therapy assistants, medical staff and administrative staff. People told us staff were usually available when needed and responded to requests for assistance in a timely manner. We observed staff providing care in a calm and professional manner, with rehabilitation and therapy needs prioritised to support people in achieving their goals and returning home where possible.

Staff had access to mandatory training relevant to their roles. However, compliance rates were below the provider’s target of 75% in several areas, including safeguarding and manual handling. This meant leaders could not be fully assured that all staff had completed essential training required to support safe care delivery. Leaders had implemented an action plan to improve compliance, including protected training time, enhanced monitoring and checks to ensure bank staff were up to date before undertaking shifts. However, improvements were still in progress at the time of our assessment.

Staff received supervision, appraisals and opportunities for professional development. The provider followed safe recruitment procedures, and leaders monitored staffing levels and skill mix. However, ongoing gaps in mandatory training compliance indicated governance arrangements for workforce development were not yet fully effective. Leaders had identified these issues and were taking action to address them, including supporting staff who were absent from work or had recently returned to complete overdue training. Overall, staffing arrangements supported the delivery of safe and effective care. However, further improvement was required to ensure all staff consistently met mandatory training requirements.

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

People were protected from the risk of infection because the environment and equipment were kept clean, hygienic and fit for purpose. People were screened for infectious diseases on admission, and those displaying symptoms were isolated where required.

Patient areas were clean, well equipped, well-furnished and well maintained. Handwashing facilities and hand sanitising gel were readily available throughout the unit, supported by clear signage promoting effective hand hygiene. We observed staff following good infection prevention and control (IPC) practices, including appropriate use of personal protective equipment (PPE), which was disposed of correctly after use.

Cleaning schedules were completed and up to date, indicating clinical areas were cleaned regularly. Staff cleaned equipment after use and applied labels to indicate when equipment had last been cleaned. IPC audits and risk assessments were completed regularly, with actions taken to address identified risks and maintain safe standards of care.

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

Staff reviewed medicines regularly and provided advice and support to people and carers to help them understand their medicines and any changes to treatment. Where appropriate, people were encouraged to develop an understanding of their medicines and take an active role in managing them, supporting their independence and preparation for discharge.

Medicines were stored securely and at appropriate temperatures, including controlled drugs and emergency medicines. Staff carried out regular checks of stock levels, expiry dates and storage conditions, with records demonstrating these were completed consistently. Prescription stationery was stored securely, and processes were in place to manage medicine safety alerts and recalls.

Staff responsible for administering medicines had completed appropriate training and competency assessments and demonstrated a good understanding of safe medicines management. Medicines administration records were completed appropriately, and we saw evidence that people received their medicines as prescribed.

The service had systems to audit medicines management and ensure medicines were prescribed, stored, recorded and disposed of in line with national guidance and local policy. Regular audits were undertaken to monitor compliance, identify risks and support continuous improvement.

The service had effective arrangements for managing waste medicines and supporting people with their medicines on discharge. Staff worked closely with the multidisciplinary team to ensure medicines supported people’s rehabilitation goals and ongoing care needs.