Archived: The Elms

Updated 7 August 2021

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 Care Act 2014.

Inspection team

This inspection was carried out by one inspector.

Service and service type

The Elms 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.

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 safeguarding team. 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 spoke to three people who used the service about their experience of the care provided. We spoke to 13 members of staff including the registered manager, regional manager, quality assurance manager, team leader, senior care assistant, administrator, three care assistants, two domestic staff members, cook and catering assistant. We also spoke to a visiting healthcare professional.

We reviewed a range of records. This included three people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision.

After the inspection

The provider sent us a variety of records relating to the management of the service, including policies and procedures and quality assurance records, which we looked at remotely.

Updated 7 August 2021

About the service

The Elms is a residential care home providing accommodation and personal care for up to 28 people aged 65 and over at the time of the inspection. It accommodates people in one adapted premises with shared facilities. The service can support up to 37 people.

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

Staff did not consistently apply good infection control practices and some areas of the home and equipment were not clean. Not all agency staff had received an induction before they started working at the service and there were times when staff were unavailable to support people. Staff did not always keep up to date records. The provider’s systems for ensuring the safety and quality of the home fell short in these areas.

People told us they felt safe and staff were knowledgeable about risks to people and followed risk assessments, which they regularly reviewed.

People received their medicines appropriately and were protected from the risk of abuse. There were systems and processes in place to learn from safety-related incidents.

There was a warm atmosphere in the home and staff worked closely with other healthcare professionals to meet people’s needs.

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.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 24 October 2018). The service remains rated requires improvement. This service has been rated requires improvement or inadequate for the last five consecutive inspections.

Why we inspected

We received concerns in relation to safeguarding. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has remained the same. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Elms on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to infection prevention and control and governance at this inspection.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information, we may inspect sooner.