Elmdene

Updated 18 April 2018

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 unannounced inspection took place on 8 March 2018 and was carried out by one inspector and an expert by experience (ExE). An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We also reviewed information we had received about the service which included notifications from the provider about incidents at the service. We used this information to plan the inspection.

During the inspection we spoke with four people, one support worker, the recovery manager, operations manager and provider. We observed how staff supported and interacted with people. We looked at four people’s care records, the medicines administration records (MAR) for one person, three staff files and records relating to the management of the service such as health and safety and quality assurance systems.

After our inspection, we spoke with one support worker and we received feedback from a member of the community mental health team involved with the service. We also received the quality monitoring report from a local authority commissioning team.

Updated 18 April 2018

This unannounced inspection of Elmdene Care Home took place on 8 March 2018. Elmdene is a ‘care home’ for adults with mental health problems. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Elmdene care home accommodates five people in one adapted building.

At the last inspection of Elmdene on 25 October 2015, the service was rated Good overall, although, we found that robust checks were not always completed around recruitment of staff. We asked the provider to comply with this requirement. At this inspection we found the service had made the required improvement and their rating remained Good.

There was no registered manager in post. The provider was in the process of registering to become the 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.

Staff employed at the service had undergone thorough checks to ensure they were fit to work with people. Staff and the provider were committed to protecting people from abuse. Staff were trained in safeguarding people from abuse and demonstrated that they understood the signs of abuse and how to report any concerns in line with the provider’s procedures. There were sufficient numbers of staff to support people at the service. Risks were assessed and management plans were developed to mitigate any risks identified. Staff followed risk management plans for people.

People’s needs were assessed with involvement of relevant professionals where required to ensure their needs were met. Support plans focused on meeting people’s individual needs and goals. People were supported to learn new skills, develop their interest, become independent; and move-on to independent living. People were supported to do the things they enjoyed and gain meaningful and paid occupation. Regular reviews took place to ensure support delivered to people continued to meet their needs.

People’s medicines were managed and stored in a safe way. Health and safety of the environment was maintained. Staff followed good infection control procedures. Staff reported incidents. The provider reviewed and took actions to prevent them from happening again. Lessons were shared with staff.

Staff were trained, supervised and had the skills and knowledge to meet people’s needs. People’s nutritional and dietary needs were met. People were encouraged to cook for themselves. Staff worked effectively with health and social care professionals to attain positive outcomes for people. People had access to healthcare services to maintain good health. The service had systems in place to enable smooth transition when people moved between services. There were suitable facilities and adaptations available for people to use.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff understood their responsibility under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. People knew how to make a complaint if they were unhappy with the service. The provider investigated complaints in line with their procedure.

Staff understood people’s needs and treated them with respect, kindness and dignity. Staff supported people to express their views and people were involved in planning their care and support. People were supported to maintain their religious and cultural values.

Staff received the support, direction and leadership they needed. There were systems in place to monitor and assess the quality of service provided. The service worked in partnership with external organisations to develop and improve the service.