Archived: Elm Lodge

Updated 23 June 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 24 and 25 May 2017. The visit on 24 May was unannounced and we told the provider we would return on 25 May to finish the inspection. The inspection team comprised one inspector and an Expert by Experience. An Expert-by-Experience is a person who has personal experience of using or caring for someone who uses this type of care service. The Expert by Experience for this inspection was the family carer of a person living with the experience of dementia.

Before the inspection we reviewed the information we held about the provider. This included the last inspection report and statutory notifications the provider sent us about significant events and incidents affecting people using the service. We also contacted the local authority’s commissioning and safeguarding adults team for their views of the service.

During the inspection we spoke with 20 people using the service, six visitors and 14 staff, including the registered manager, head of nursing, nurses, care staff and domiciliary staff including domestic, maintenance and catering staff. We looked at the care records for seven people using the service and staff recruitment and training records for six members of staff. We reviewed other records including the medicines records for 20 people using the service and checks and audits the provider carried out to monitor quality in the service and make improvements.

During lunch on one unit for people living with the experience of dementia, we carried out a Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We saw all communal parts of the service and some people’s bedrooms, with their permission. We also spent time observing activities that staff organised for people on both days of the inspection.

Updated 23 June 2017

This inspection took place on 24 and 25 May 2017. The visit on 24 May was unannounced and we told the provider we would return on 25 May to finish the inspection. The last inspection of the service was in October 2015 when we rated the service as good for all five outcomes.

Elm Lodge is a care home providing nursing and personal care for up to 75 older people, some living with the experience of dementia. The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider had systems in place to safeguard people using the service. Staff understood and followed the provider’s procedures if they had concerns about people.

There were enough staff to provide care and support and the provider’s recruitment checks were designed to ensure the staff were suitable to work at the service.

Staff assessed possible risks to people using the service and took action to mitigate risks they identified.

The provider had assessed people’s capacity to consent to the care and treatment they received and staff made sure people consented to their care as it was offered. Where people lacked the capacity to make specific decisions the provider had acted in the person’s best interest and had consulted with those who were important to the person.

The staff received the training, supervision and support they needed to care for people safely and meet their needs.

People’s nutritional needs were met and staff worked with the GP and other healthcare professionals to make sure people’s healthcare needs were met. People received their medicines safely and as prescribed.

People who used the service and the relatives we spoke with all felt the staff were kind and genuinely cared about them or their family members.

Staff we spoke with could explain how they provided compassionate care and support for people. They spoke passionately and caringly about the people they supported and showed a genuine warmth and empathy for each person using the service.

The registered manager was able to give us examples where the care they provided in the service had made a difference to people’s lives.

Staff cared for and supported people in ways people wanted. People’s preferences and personal wishes were recorded in their care plans. People had access to a range of organised activities.

The provider had systems for managing and responding to complaints they received.

The service had a qualified and experienced manager. People living at the service, staff and visitors told us they found the manager approachable and said they felt the service was well managed.

The provider carried out a number of different audits and checks which enabled the manager and staff to monitor the quality of the service and make improvements. Records were well maintained, accurate and up to date.