Elmwood Residential Home Limited

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 identified 1 breach of the legal regulations. People were not consistently protected against the risks associated with unsafe medicines practice. Whilst people’s risks were assessed, it was not clear that people had received care interventions to reduce known risks. We identified risks within the environment and fire safety advice had not been addressed in a timely way. This was a continued breach from the last inspection. However, since the last inspection the provider had ensured staff had received appropriate training to meet the needs of people using the service and was no longer in breach with the relevant regulation. People at the service told us they felt safe and said there were enough competent staff on duty to meet their needs. Staff were recruited safety.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they were well cared for. The service had a safety focussed approach to care. People and their relatives told us they would be comfortable to raise concerns or complaints. People felt any issues raised would be listened to. One person commented, “We are not afraid to say anything if we need anything. They get on it and work it out.”

Staff understood reporting processes for incidents and accidents to ensure they were appropriately escalated. The manager had systems and process in place to monitor incidents and accidents to ensure safety incidents were responded to appropriately.

There was a service improvement plan in place which was used as part of the providers continual improvement of the service. There were systems to monitor complaints for continued learning and development. The service management had oversight of incidents and accidents. However, there were no systems to monitor and learn from incomplete or inaccurate record keeping.

People were supported in a service where any concerns relating to health and welfare were identified and action was taken. People said they felt staff understood their needs and helped them if they needed healthcare. One person commented, “On one occasion they did call the doctor, they would see to me alright.”

We discussed pathways and transitioning for people with the registered manager. They explained that people's way of transition from or to the local hospital in a planned process but also very often in emergency situations. We reviewed examples of where the service had supported people in a co-ordinated approach with other professionals to ensure they were able to return to their own homes or other suitable independent accommodation.

The information we received from healthcare professionals who worked closely with the service was mostly positive. One told us, “Referrals are timely and appropriate suggesting they are responsive to residents’ needs.” Another comment we received was, “They often seek professional advice when needed and act upon this accordingly, to ensure good outcomes for each and every resident within the placement.”

There were processes to support people and their families to have access to healthcare professionals where required. People had clear Treatment Escalation Plans that had been discussed with them and their GP. There were processes in place that ensured where people were taken or admitted to hospital, key information would be sent with them for other healthcare professionals to use.

People and relatives told us they felt safe at Elmwood Residential Home. No concerns were raised with the assessment team and we received positive feedback about the staff and management team that supported people. One person we spoke with told us, “I feel very safe, there is always somebody about and there is a bell to ring.” A relative said, “[They are] completely safe, because they are so attentive and so willing to do anything.”

Staff understood their responsibilities in relation to identifying and escalating safeguarding concerns. Staff told us they have received training in safeguarding. Staff understood the different types of abuse people could be exposed to, for example physical or financial, and told us they would go directly to the service management with any concerns they had. Staff were able to identify external agencies they could raise concerns with.

We observed staff were respectful towards people. Our observations were positive and people looked at ease with staff. We found no evidence of unnecessary restrictions on people, however where restrictions were in place, for example the use of bedrails, records showed the need for them had been assessed but the Mental Capacity Act 2005 had not been consistently followed.

There were policies and process in place for staff to follow should they identify a safeguarding concern. Safeguarding referrals had been escalated where required and we received positive feedback from a professional about how the service had been working with them during a concern that had been identified. There were process to ensure deprivation of liberty applications had been made where required.

People and their relatives told us they felt risks to their health, safety and welfare were managed well within the service. Comments from people included, “They look after me quite well, they know what to do.” Relatives comments included, “[Deputy manager] is very good at keeping us informed. They are good at immediately telling us if [person’s identity] not very well or something is wrong. [Deputy manager] is a brilliant communicator.” Whilst people and relatives were positive, we found elements of care provision that placed them at risk.

Staff who provided feedback to us were aware of risks posed to people. They were able to advise us they had access to care plans and risk assessments. Some staff told us they were updated with any changes to the level of risk to people by the service management and in meetings. The registered manager stated care plans were completed with people and relatives where appropriate.

We observed equipment was in place to support staff to manage risk of harm to people. For example, bed rails and pressure relieving mattresses. Staff were observed supporting people safely in the least restrictive way possible. Where safe to do, people were openly encouraged by staff by staff to be independent with mobilising and moving around the service.

The processes and systems in place to manage potential risk of harm to people were not effective. Whilst the provider had a system to record how risks were managed, for example repositioning charts and records to show pressure relieving equipment was operating effectively, these records were not completed as required. Records showed multiple examples of where care interventions had not been recorded as being completed as assessed. Whilst we did not identify significant impact to people this placed them at risk. There was no effective process in place to monitor if these records had been completed.

People were not cared for in an environment that fully protected them from the risk of harm. Whilst people’s feedback was positive about the environment in which they were cared for, we identified areas for improvement. People were placed at risk, as not all areas of the environment were fully compliant with published guidance.

Staff told us they had received training on the use of the equipment within the service and felt competent using it. The provider who was present on the day of the assessment provided documentation to confirm equipment was maintained as required. We received feedback from the provider that there were currently no window restrictor audits in place. This could have identified the concerns we found during the assessment.

During our assessment we observed the environment to be clean, tidy and well-maintained. Equipment in the service used to support people was observed being used correctly by staff. People were observed to be at ease with staff who were supporting them using mobility equipment. However, during our observations we identified that not all windows on the first floor of the service were compliant with published Health and Safety Executive guidance. They were not fitted with the required tamper-proof fixings and could be easily opened to their maximum capacity. This exposed people using the service to risk.

We reviewed the systems and processes in place relating to the management and oversight of environmental risk and safety. Whilst some processes were effective the absence of others exposed people to risk. The provider confirmed that there were no systems in place to audit window restrictors and associated safety. Additionally, we found risks associated with fire safety, for example, despite a risk being identified during a fire risk assessment conducted in January 2024 by an external consultant that no fire evacuation drills had been completed, no action had been taken by the provider. This placed people using the service and others at risk. At the time of our assessment, children were living in the service due to exceptional circumstances, however no appropriate risk assessment relating to this had been completed.

People and their relatives were happy with the quality and number of staff. All commented positively on the caring nature of staff. One person commented, “I feel very safe, there is always somebody about and there is a bell to ring.” Another person said, “They are quick, they come quite quickly and make sure it’s alright.” Feedback around staff competency was generally positive, with one person telling us, “They look after me quite well, they know what to do.”

Staff told us the staffing levels were sufficient and they were able to meet people’s needs. One staff member told us, “Definitely enough staff here.” Another said, “The numbers are always maintained and because staff do not work massively long hours, there is usually people to help cover and we have also now increased the number of staff we have on the night shifts.” The registered manager told us that whilst there was no formal dependency tool in place to support staffing levels, staff deployment was kept under continual review and adapted to people’s changing needs. Staff told us they were very well supported with induction and ongoing training.

On the day we visited the service, we observed there were enough staff to support people. Staff appeared well trained and competent when performing their roles. People were clearly at ease with staff and we observed positive interactions and relationships. We found staff were engaged and person focussed during the lunch period, supporting people appropriately and respectfully. People appeared to enjoy communal activities which occurred throughout the day. We saw people smiling and laughing with staff.

There were processes to ensure safe recruitment practices were undertaken. Records we reviewed showed staff were employed with relevant documentation in place to confirm their suitability. The registered manager and other senior staff in the service continually kept staffing deployment under review to ensure people’s needs were met. There was a training record for all staff employed by the service to ensure mandatory and additional training was completed.

People and relatives we spoke with were positive about the cleanliness and appearance of the service. No concerns were raised with us in relation to infection control practices. People said they lived in a clean service and that staff wore the appropriate personal protective equipment when supporting them. One person said, “It’s very clean. I can’t really fault it.”

The registered manager told us that there were dedicated housekeeping staff employed within the service which we saw on the day of the assessment. Staff told us they received training in infection control which was supported by training records. No concerns were raised by staff in relation to personal protective equipment being available.

We observed the service was clean and there were no unpleasant smells. Communal areas and people’s bedrooms were clean and tidy and we saw staff undertaking cleaning tasks throughout the day. Staff were observed using personal protective equipment where appropriate while supporting people.

Whilst we observed the service was clean, tidy and free of odour, there were insufficient systems and processes in place to ensure people, visitors and those employed within the service were fully protected against infection control risks. The providers policy did not provide any guidance on how to manage an outbreak effectively and what actions to take. There was no information on the governance framework in place for infection control risk mitigation. The registered manager told us there was no infection control auditing undertaken that would identify any areas of risk or staff practice improvement that could be improved to mitigate potential risk.

People’s medicines were seen to be given in a safe and caring way. Staff took time with people to support them to take their medicines correctly. People could look after their own medicines if it had been assessed as safe for them to do this. If medicines were prescribed to be given at specific times, then these were seen to be given appropriately in a timely way.

Staff told us they were supported with medicines by the managers, and that generally the systems worked well. They could describe how to report any issues or errors. Staff told us they received medicines training by the manager, and e-learning modules. They said that they had competency assessments and we saw records that showed these had been completed.

Electronic Medicine Administration Records (MAR) charts were used and showed that generally medicines were given as prescribed. However, some of these records lacked photo ID for residents and/or allergy status was not recorded. Medicines were stored securely, and there were suitable systems for ordering and disposal. However, there were gaps in medicines fridge temperature recording. Maximum and minimum range were recorded and although these were all seen to be suitable over the last 2 months, there were gaps of up to 8 days with no record. This meant staff could not have been assured that medicines were being stored at the correct temperature at the time they were used. Detailed and person-centred information for ‘As Required’ medicines was not always available in care plans or on the electronic medicines system, to guide staff when it would be appropriate to give doses. When pain relieving patches were applied it was not always recorded where they were placed, meaning it was not possible to tell if these were being rotated appropriately. There was a policy available to guide staff. However, this did not refer to best practice guidance or cover all the recommended areas of medicines management. There were systems in place to record and investigate any medicines incidents or errors to try to prevent a recurrence. There were no risk assessments for flammable topical preparations. However, a policy and suitable systems were put in place following our site visit. There were regular checks recorded for controlled drugs. However, no other recorded medicines audits were taking place to provide oversight of medicine management or to identify these areas needed for improvement.