Archived: Elm Lodge

Updated 9 October 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 was planned to check 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 comprehensive inspection took place on 5 and 6 September 2018. The visit on 5 September was unannounced and we arranged with the registered manager to return on 6 September to finish the inspection.

One inspector, an assistant inspector and an expert by experience carried out the inspection. 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 we reviewed the information we held about the provider and the service. This included information the provider gave us when they registered the service and statutory notifications they sent us. Notifications are for certain changes, events and incidents affecting the service or the people who use it that providers are required to notify us about. We also contacted eight health and social care professionals who worked with people using the service. We received comments from two people.

We also used information the provider sent us in the Provider Information Return on 9 July 2018. This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection site visits we spoke with 18 people using the service, seven visitors, the registered manager, head of nursing and head of care, nursing, care, catering and domestic staff.

We reviewed the care records for eight people using the service, staff recruitment, supervision and training records for six members of staff, medicines management records for 14 people and other records related to the running of the service. These included complaints, accidents and incidents affecting people using the service, maintenance and equipment service records, audits and checks the provider carried out to monitor quality in the service and make improvements. We also carried out a Short Observational Framework for Inspection (SOFI) observation exercise during lunch on one unit. SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Updated 9 October 2018

This comprehensive inspection took place on 5 and 6 September 2018. The visit on 5 September was unannounced and we arranged with the registered manager to return on 6 September to finish the inspection. This was the first inspection of the service after the provider changed in October 2017.

Elm Lodge is a ‘care home’. 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.

The service was purpose-built and accommodates up to 75 people across five separate units, each of which has separate adapted facilities. One of the units specialises in providing care to people with nursing care needs who are living with dementia. Three units provide support for people who require residential care and one of these units is for people who are also living with the experience of dementia. The fifth unit provides care for people with general nursing care needs.

The service has 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.

There were systems in place to protect people from abuse and staff had completed training in safeguarding people.

The provider assessed risks to people using the service and staff and acted to mitigate any risks they identified.

The provider completed checks on staff before they started work in the service to make sure they were suitable to work with people using the service.

People received the medicines they needed safely and as prescribed. People had access to the healthcare services they needed. People’s care plans included information about their nutritional needs and staff kept records to show that people had enough to eat and drink.

Care and housekeeping staff kept the building clean to help control the risk of infection.

Nurses and care staff delivered people’s care, treatment and support in line with current standards and guidance.

Staff had completed training the provider considered mandatory and additional training to meet the care needs of people using the service.

Staff sought consent from people they cared for in line with the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

Staff in the service treated people with kindness, respect and compassion.

The provider involved people using the service and their families in reviewing the care and support people received.

All staff working in the service respected people’s privacy and dignity and encouraged people to remain as independent as possible.

People had an individual plan that detailed their care needs and preferences for the staff who cared for and supported them.

The provider had a policy and procedures for responding to any complaints they received.