Elmsdene Care Home

Updated 11 August 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was completed by 1 inspector.

Service and service type

Elmsdene Care home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Elmsdene Care home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced. Inspection activity started on 6 June 2023 and ended on 29 June when feedback was provided. We visited the service on 6, 12 and 13 June 2023.

What we did before the inspection

We reviewed all information we held about the service and discussed the service with stakeholder groups to gather feedback. We also reviewed available information in the public domain. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 11 staff including the registered manager, director who is also the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spoke with maintenance, domestic, laundry and care staff and with 4 people who used the service. We spoke about their experiences of living and working in the home. We reviewed care plans for 7 people and medicines and accident records for all people in the home. We reviewed management information to aid the safe delivery of provision in the home and looked around the environment of the home including bedrooms, communal areas and the kitchen and laundry. We also observed the delivery of support and staff interactions with people using the service.

Updated 11 August 2023

About the service

Elmsdene care home is a residential care home providing support for up to 33 people. The home supports people living with various types and levels of dementia. The home is over 2 floors and has a large lounge, dining room and separate television room. A kitchen and laundry are located on the ground floor and the upper floor is accessible by both a lift and stairs. At the time of the inspection the home was supporting 23 people.

People’s experience of using this service and what we found

We found blanket decisions had been made across the home which affected people’s safety and breached the requirements of different legislative frameworks, including the Mental Capacity Act, the Health and Social Care Act and the Human Rights Act.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

We identified concerns around how medicines were managed including how people could access medicines at the time they were prescribed or needed. We also identified risk management was not as developed as was required to ensure risks to people could be mitigated where possible. Governance systems were beginning to develop but audits and reviews in place only monitored small numbers of peoples’ records each month. The analysis of information collated through audit, to drive improvement, required further development.

There was enough available safely recruited staff to meet people’s needs and the home was clean and tidy. The home had recently changed management and a new system was being updated to provide more effective care planning. Staff and people, we could speak with, told us they were happy. The provider reacted immediately when serious concerns around people’s rights were highlighted and took steps to rectify the circumstances of the concerns.

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 13 October 2020) and there were breaches to the regulations. 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 the provider remained in breach of regulations.

Why we inspected

We carried out an unannounced focused inspection of this service on 21 August and 3 September 2020 and found breaches of legal requirements. We found beaches in relation to suitable staffing 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 and well led which contain those requirements.

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 inadequate. This is based on the findings at this inspection.

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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Elmsdene care home on our website at www.cqc.org.uk.

We have found evidence that the provider needs to make improvements. Please see the safe and well led key question sections of this full report. The provider took immediate action to address concerns identified with the use of yale locks to bedroom doors and assured us they would address blanket bans on people eating food in their bedrooms.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, staff competence, medicines management, protecting people from abuse and good governance at this inspection.

You can see what action we have asked the provider to take at the end of this full report.

Follow up

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures.’ This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.