Elm House Care Home

Updated 2 December 2023

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.

Inspection team

The inspection was undertaken 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 House Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Elm House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 19 October 2023 and ended on 23 October 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. 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 (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 7 people that use the service and 9 relatives. We spoke with 12 members of staff including care staff, the registered manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We looked at a range of records including 3 people’s care plans, risk assessments and medicines records. We looked at health and safety records, policies and procedures and audits. We looked at 3 staff recruitment records and requested training records.

Updated 2 December 2023

About the service

Elm House Care Home is a residential care home providing personal care to up to 34 people. The service provides support to older people, people with a physical disability and people with a sensory impairment. At the time of our inspection there were 29 people using the service. The home is set over 2 floors with communal areas and a garden for people and their relatives to use.

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

Systems needed improving to make sure people were adequately protected from the risk of abuse and to make sure lessons were learned following mistakes. Risks to people’s health and wellbeing were not always assessed and mitigated effectively. Staff were not always recruited using safe processes. Although staff were experienced, they did not receive regular training to update their knowledge and skills, which we have made a recommendation about.

We found gaps in the governance processes of the service although this had been identified by the registered manager and provider prior to the inspection, and plans were being made to address.

People and relatives gave positive feedback, one relative said, “[My relative] is comfortable in Elm House, I can rest knowing they are being looked after.”

People were supported to take their medicines safely. The home was kept clean, tidy and comfortable.

People were supported to eat and drink healthily, and people commented that they enjoyed the meals. A relative said, “The food is very good,” another relative said, “My relative loves the meals and eats better than they did at home.”

The home had a comfortable atmosphere and people could decorate their rooms according to their personal preference.

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 and their relatives spoke highly of the managers and felt that any concerns would be dealt with effectively and in good time. Staff enjoyed their jobs, one person supported said, “The staff are brilliant, they are kind and caring and like to have a good laugh.”

The registered manager had plans to further his own knowledge and skills and worked well with external agencies.

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 good (published 20 July 2021).

Why we inspected

We received concerns in relation to managing people’s needs effectively should their health deteriorate, and staff training. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe section of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement and recommendations

We have identified breaches in relation to monitoring risks to be able to improve the service, assessing risks to people’s health and wellbeing and staff recruitment.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.