Elm Lodge Residential Care Home

Updated 15 June 2022

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.

As part of this inspection we looked at the infection control and prevention measures in place. This included checking the provider was meeting COVID-19 vaccination requirements. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team:

This inspection was carried out by an 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.

Service and service type

Elm Lodge is a ‘care home.’ People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with CQC. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced. We visited the service on 29 March 2022. The inspection activity ended on 20 May 2022.

What we did before the inspection

We reviewed information we had received about the service. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We toured the building and spoke with eight people who used the service and one visiting relative about their experience of the care provided. We spoke with one visiting health care professional. We also spent time observing people’s care and interaction with staff in the lounges and dining areas to help us understand the experience of people living at the home.

We spoke with the registered manager, two member of ancillary staff and five members of the care team, including senior carers.

We saw the day to day care records, risk assessments and care plans for three people. We observed people receiving their medicines and looked at three people’s medicines records. We also saw monitoring records in relation people’s nutrition and hydration, weight and oral care. We looked at personnel and recruitment records for three staff.

After the visit we reviewed further records in relation to the management of the service, which were provided to us remotely. This included records relating to the provider’s quality and safety systems and processes, including audits and meeting minutes.

We held a remote, online meeting with members of the management team on 20 May 2022 to discuss our findings.

After the inspection

We continued to seek clarification from the provider to validate evidence found.

Updated 15 June 2022

About the service

Elm Lodge is a residential care home providing personal care to people aged 65 and over. The service can support up to 17 people. Elm Lodge is a converted property. It has communal areas on the ground floor with bedrooms on both the ground and first floor. At the time of the inspection 16 people were living in the home.

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

The provider had taken action to ensure people's care met their needs and preferences. Risk assessments were in place and reflected people’s needs. The home and equipment were clean.

People told us staff were caring and kind and listened. We saw staff interacted with people with warmth. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People were provided with opportunities to take part in meaningful activities.

Systems of governance were improved since the last inspection. Quality monitoring systems highlighted and addressed shortfalls in the service. People were generally happy with the care provided and felt consulted and valued. An accurate, complete and contemporaneous record was maintained for each person.

Improvements had been made to staff recruitment records to show staff were recruited safely and there were enough staff to meet people’s needs. The provider had continued with their schedule of redecoration and improvement of the building. Staff had received medicines training and we observed a member of staff administering people’s medicines safely.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 15 October 2020) and there were breaches of regulation. 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 improvements had been made and the provider was no longer in breach of regulations.

At our last inspection we recommended the registered provider considered staffing requirements to ensure all aspects of the service were operating in line with good practice guidance. We recommended the provider considered current guidance on medicines management and took action to update their practice accordingly. At this inspection we found the provider had acted on the recommendations made and had made improvements in these areas.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

We undertook this focused inspection to check the provider 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, Caring, Responsive and Well-led which contain those requirements.

For those key question not inspected, we used the rating awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Elm Lodge Residential Care Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We continued to seek clarification from the provider to validate evidence found.