Elmcroft Care Home

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 at all quality statements for Safe at this assessment. The service was not safe. This showed a decline since the last inspection. Risks assessments were poor or incomplete, including for serious safety concerns such as self-harm or suicidal ideation. Safeguarding systems and processes were not effective to protect people from abuse and neglect. Lessons were not learned to reduce the risk of reoccurrence when safety incidents occurred. People did not always experience safe pathways of care, and we received negative feedback from professionals who work with the service. Improvements were needed to ensure safe environments, including in infection prevention and control. Improvements were needed to recruitment processes. People did not always receive their medicines safely and as prescribed. During our assessment of this key question, we found concerns about unsafe care and treatment, safeguarding and staffing which resulted in 3 breaches of the legal regulations. You can find more details of our concerns in the evidence category findings below.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a failure to analyse and consider learning from incidents to improve people’s experience of care. A person’s daily care records showed they were upset by constant staff presence in their bedroom, but there was no recorded action taken in response. On 1 day, the person said to staff, “Why are you watching over me like a hawk?”. Later the same day they became increasingly anxious, stating to staff, “I don’t want to be watched over like a baby, get out of my room or I will call the police.” Whilst the person was supported with 24 hour 1:1 care, the lack of learning about the best way to support them did not safeguard the person and placed them at risk of escalating distress.

Staff were not always aware of serious incidents which had taken place at Elmcroft Care Home to prevent repeat incidents and embed good practice from lessons learned. A person had an unwitnessed fall and sustained multiple rib fractures, but post-fall observations were not consistently completed by staff, so the extent of their injuries were not noticed. A staff member told us, “There was an incident with [person], but I wasn’t there, so I don’t know the details.” Incident records showed another person had fallen after this and also had no consistent post-fall observations completed despite a potential head injury. The provider told us disciplinary action had been taken, and information shared with the wider team going forwards.

As the provider failed to identify issues and concerns, and there was poor oversight of accidents, incidents and safeguarding, there was no meaningful way in which staff could learn lessons from adverse events to reduce the risk of reoccurrence. Any recommendations or findings that were identified were not always actioned. This placed people at the continued risk of harm, including from potentially avoidable events. For example, audits identified concerns not all staff had practical moving and handling training and a lack of post-fall observations for suspected head injuries, but no effective action had been taken.

We received mixed feedback from people and their relatives as to whether referrals and transitions were planned and organised collaboratively. A person’s relative told us, “Staff will call a GP and other healthcare professionals if needed and will promptly make referrals if needed. I am not sure what may be in place for helping people who may have a mental health condition.” Another person’s relative said, “I have recently only been told the evening before that [my person] has a hospital appointment the following day and I have asked for at least a few days’ notice so that I can attend.”

Admissions and discharges to and from hospital did not reflect joined-up care. A staff member told us, “We get no update about people when they return from hospital. We check them for bruises and pressure ulcers and record anything on a body map we take their vital signs. Nurses do the care records, but they are not updated or revised to show any changes in current needs.”

The provider failed to prioritise continuity of care and collaboration in relation to identifying concerns and making timely referrals, and we received negative feedback about staff knowledge and understanding of risks posed to people. A professional told us, “The interactions I have had with Elmcroft Care Home varies dependant on which member of staff is on duty. The care staff lack understanding about catheters, physical health, sepsis risks, UTIs, dementia, mental health conditions and how to accurately document events/concerns about a client in their care.”

Systems and processes in place failed to proactively consider, assess and manage risks to people when moving between services. There was a poor relationship with key stakeholders such as the GP practice, impacted by frequent changes to managers in post at Elmcroft Care Home. There was also an embargo on any new people being admitted to the service by health funders at the time of our assessment, due to safety concerns about catheter management and poor escalation by the service to other healthcare professionals.

People assessed to require 24-hour 1:1 care were not safeguarded, sustaining serious unexplained injuries despite records stating they needed constant staff supervision. A person with funding for 24 hour 1:1 care had sustained an unexplained fractured hip and an unexplained black eye in 2 separate incidents. There was also high level of unexplained bruising and skin tears amongst people more widely. A different person’s relative showed us a photograph of their loved one with a black eye, and told us, “You ask if [person] is safe here early on, well look at this. How did that happen? Nobody here knows how, they all say, ‘I don't know how that happened’. But it did happen, and I would like to know how [my person] has ended up looking like that.”

Senior leaders did not demonstrate an understanding of local safeguarding requirements. The Nominated Individual told us they had not made a safeguarding referral in instances where a person attempted suicide or was assaulted by another person living at the service. Staff told us they were frightened to raise concerns due to a blame culture and were not confident concerns shared with leaders would be acted upon. A staff member told us, “I feel that if concerns were raised, they may be dismissed and not actioned. Information is still passed onto management.” There were also no recorded de-briefs for staff who had been injured during incidents where people became distressed.

For people with 1:1 support needs, close observation and supervision including in people’s bedrooms had not been considered as a trigger for distress or an infringement on their dignity, personal space and human rights. We observed people being constantly touched by staff providing 1:1 support, which restricted people’s freedom of movement. Records corroborated our observations, such as an incident where 4 staff members were present to shower 1 person, which could be perceived be the person as restrictive, threatening and degrading. Staff were also not equipped to support people when expressing sexualised behaviour.

Systems and processes were not in place and operating effectively to safeguard people from potential abuse. There was no effective oversight of incidents, accidents and safeguarding concerns which meant they were not investigated and reported in a transparent way to reduce the risk of reoccurrence. We found evidence of multiple injuries such as bruising and skin tears which had not been properly recorded as accidents and incidents. We had to raise an individual safeguarding alert with the local authority for a person at risk of suicidal ideation, and a further organisational safeguarding alert regarding widespread poor practice. We identified concerns relating to unexplained injuries and medicines which led the provider to raise 2 additional retrospective safeguarding referrals. During our assessment, the GP practice and health commissioners also made multiple safeguarding alerts.

Whilst we received feedback that some people felt safe at Elmcroft Care Home, people and their relatives were not informed of risks, as risks were not assessed by the provider in a robust or timely way. People and their relatives were not always involved in the risk assessment and care planning process, with multiple people’s relatives stating they had never seen a care plan. Other feedback showed relatives were not always assured about safety, with comments such as, “It’s a good thing I'm here to visit regularly” and, “We've thought on some occasions to move [person] to another home.”

We shared concerns with the senior leadership team about poor quality care planning and risk assessments. The provider responded to CQC feedback and sent an updated care plan for review as an example of proposed standards going forward. However, this document still contained unsafe information which placed a person at the risk of choking and was still not fit for purpose.

We observed some people expressing their emotions in a way which placed them and others at risk. There was a known history of some people leaving the building which could impact on their safety. We observed 1 person repeatedly trying exit doors but did not receive adequate staff support. We were informed the person later left the building on multiple occasions, as this risk had not been managed.

Care plans and risk assessments were generic, incomplete or inaccurate. This placed people at serious risk of harm, including from significant concerns such as suicidal ideation, sexual safety issues and self-harm. We had to seek formal written assurances from the provider during the inspection process to check people were safe but were provided with incomplete and inaccurate information. We informed the local authority safeguarding team of our concerns. Care plan documents also failed to assess and mitigate risks in relation to areas such as supporting people to move safely, catheter care and choking. Monitoring systems were not effective. Daily records did not show for people with indwelling catheters that their fluid intake and output was effectively monitored which would give an indication of potential blockage and retention. Whilst staff recorded the amount of fluid drunk, they did not record the amount of urine emptied from catheter bags.

We received mixed feedback from people and their relatives about the environment. A person’s relative told us they felt bedrooms needed to be updated. Another person’s relative told us, “The quality of the building has been improved”. However, we identified multiple safety issues in relation to the environment.

People were not always cared for in a safe environment designed to meet their needs. The provider accepted our findings and took steps to address this. However, it had not been identified or prioritised prior to our inspection, demonstrating a failure by senior leaders to recognise serious environmental risks. The Nominated Individual told us there were plans to improve the environment, including steps to make it more dementia friendly.

Wardrobes were not affixed to walls in people’s bedrooms, including those who independently mobilise, placing them at the risk of potential crush injuries. Whilst the provider immediately took action to address this, it had not been independently identified. We also observed some fire escape walkways narrowed by the storage of equipment.

Ligature risks were not identified and assessed even where this was a known issue placing people at significant risk of harm. Personal Emergency Evacuation Plan (‘PEEPs’) did not cover all information required in the event of an emergency. A person who had a gate across their bedroom door did not have this information recorded in their PEEP to guide emergency services. This could pose an obstruction to evacuation in a fire, particularly if obscured by smoke. Some safety checks were in place in relation to the building, such as an external health and safety audit and fire checks. However, the provider’s own health and safety audits were not effective in identifying and acting on all environmental risks.

We received mixed feedback from people and their relatives about staffing. Whilst people were positive about regular staff who were described as being friendly and approachable, there were some concerns raised about the impact on people from staff deployment and lack of meaningful engagement. A person’s relative told us, “We were unhappy with [person’s] care here, [person] was just left in their bedroom. We tried to help getting [person] out of their room. Staff said they didn't have enough chairs, so we bought [person] one for the lounge and [staff] took it back into [person’s] bedroom.” Another relative expressed concern that short staffing had impacted on timely continence support.

Staff told us they were regularly overstretched and received limited support from management. No account of staffing levels was taken when planning activities outside of the home, and no extra staff were allocated. A staff member told us, “It’s really hard working here sometimes. We don't always get our breaks which is hard because then we're working for hours non-stop. It's mainly because we have to relieve other [staff].” Another staff member said, “It doesn’t affect the residents but us as staff we try our best to help the residents sometimes, we will sacrifice our breaks. We will sacrifice our time; we need to keep an eye on them. We keep the residents safe.” Another staff member told us, “I haven’t had any supervision. No appraisal either.” The provider told us they would review staff breaks and put supervisions in place.

We saw staff providing well-intentioned but intuitive care, and interactions showed a lack of staff awareness in areas such as dementia care, supporting people exhibiting distress, infection prevention and control and understanding modified diets. We saw care staff were also being asked by the provider to complete ancillary duties such as washing and wiping dishes instead of kitchen staff, further impacting on staffing levels. We also found a staff member responsible for 1:1 care asleep on duty during our inspection site visit. After the assessment, the provider told us they would take action to reduce the length of shifts staff were supporting people with 1:1 care needs, to reduce staff fatigue.

The provider failed to ensure staffing levels, competency and training were adequate to meet the needs of people using the service. This meant people did not routinely have access to key elements of care, including meaningful leisure time, emotional support, encouragement to eat, adequate supervision to keep them safe and access to regular showers. Staff had no appraisals, and regular supervision was not in place to support staff development in their roles. Induction processes were poor, and we identified a new staff member with no on-site induction or mandatory training who told us they had researched dementia care on social media in place of any other guidance. Improvements were required to recruitment practices, to check new staff were safe and suitable for the role. The provider also failed to consider the impact on staff who were routinely working very long hours.

Whilst we received some positive feedback from people and their relatives, this did not reflect our observations of areas outside of public view. A person’s relative told us, “[Elmcroft Care Home] is very clean and tidy”. However, another person’s relative told us, “At Christmas [person] dropped a biscuit on the floor, under [their] bed. I deliberately didn't pick it up, so waited to see how long it was before it was cleaned up. It took days and when they eventually moved [person’s] bed it was very dirty where it was.”

The approach to assessing and managing potential infection risks was not effective. We were informed by leaders the acting manager had come on site with symptomatic COVID-19 to collect a laptop, placing people living within the nursing home at unnecessary risk of acquiring infection. Staff were not clear on personal protective equipment (PPE) requirements as a result, with inconsistent use of face masks seen. Staff could tell us how to employ infection control measures such as the use of PPE, but this did not always correlate with our observations.

Whilst some areas of the service were clean and well-maintained, others were not. We identified concerns relating to sluice rooms, the laundry room, laundry closet and shared shower and bathrooms. This included unsafe waste disposal, clutter and items stored on the floor, paint peeling from walls and unclean shower chairs and drains. This placed people at the risk of infection. We observed a person’s bedroom had a strong malodour on multiple days of inspection. Staff PPE practice was inconsistent and included staff members touching PPE face masks and serving food without performing hand hygiene, and a used face mask screwed up in a staff member’s pocket.

People were not protected as far as possible from the risk of infection because the provider failed to ensure premises and equipment were kept consistently clean and hygienic. Audits did not identify our findings in relation to poor maintenance and infection prevention and control concerns. Where issues were noted in audits, such as the poor condition of sluice rooms, no action was taken. There were also no detailed cleaning schedules for staff to follow. The provider told us they had commenced works to improve the sluice rooms and laundry to ensure they were clean and fit for purpose, following our feedback.

People were mostly supported to take their medicines correctly and at the right time. This was recorded on their electronic medicines administration record (eMAR). Individual needs and preferences were considered during medicines administration rounds. Staff treated people with dignity and respect. However, 1 person requested pain relief and staff were unable to respond appropriately. Analgesia had not been prescribed for that individual and there was no mechanism in place for staff to be able to administer a homely remedy. Another person required a review as they were experiencing difficulty in swallowing, but this was not reflected in their care plan.

Staff told us there was information available to them which enabled them to manage medicines safely and effectively and they had received medicines training. Staff told us they did not receive any feedback or learning from incidents. The Nominated Individual told us they had identified a person given medicine they were not prescribed following our request incidents were reviewed, leading to a safeguarding referral being made. Staff from the GP practice visited weekly to review people. We were told there were some issues with completing electronic records due to internet connectivity. A staff member said, “Sometimes there are issues with the internet when doing MARs, they are delays in the documentation. Sometimes in a week it can happen 2-3 days.”

The service did not always have systems for appropriate and safe handling of medicines, but actions were taken promptly to rectify the issues once identified by inspectors. Allergies were missing from the electronic medication administration records (e-Mars), this was actioned on the day of our inspection. Authorisations for the safe and appropriate administration for end-of-life medicines were not always in place or hadn’t been reviewed recently. There was no access to homely remedies so staff couldn’t respond in a timely manner to minor ailments and the recording of transdermal patch applications was poor. There were also no contingency measures for e-MARs in case of internet outage. The provider told us they had acted to put this in place. However, issues identified at our inspection had not been dealt with through the provider’s own processes, such as medication audits.