Elm House Nursing Home

Updated 9 January 2024

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 carried out by 1 inspector.

Service and service type

Elm House Nursing 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 Nursing Home is a care home with 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 not a registered manager in post. A new manager had been in post for 10 months and had submitted an application to register. We are currently assessing this application.

Notice of inspection

This inspection was unannounced on the first day and announced on the second day.

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. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We carried out a walk round of the home to ensure it was safe and suitable to meet people's needs. We also observed the delivery of care and support at various times throughout the day. We spoke with 5 people who lived at the home, a representative for the provider, the manager, the deputy manager, the cook, the maintenance person, the administrator, the activity co-ordinator, the head of care and 2 members of care staff.

We looked at records in relation to people who used the service including 3 care plans, medication records and systems for monitoring the safety and quality of the service provided. We also looked at quality assurance records.

After the inspection

We spoke with 3 relatives of people being supported at Elm House Nursing Home, to help us understand their experience of the care and support received by their loved one.

Updated 9 January 2024

About the service

Elm House Nursing Home is a residential care home providing personal care to up to 32 people. The service provides support to older people, including those living with dementia. At the time of our inspection there were 31 people using the service.

Elm House Nursing Home is a large, adapted house with 4 floors, with lift access to all floors. There was a communal lounge and a dining room located on the ground floor. People also had access to a private and enclosed rear garden.

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

Some checks about the safety of the environment were not up to date. (Fire safety and window restrictor checks were overdue for completion). Systems to analyse risks to help identify any trends or patterns required strengthening.

We have made a recommendation about the further development of risk management processes.

We were assured people received care and support based on their needs, however, some care plans required additional detail to provide specific guidance for staff.

Risks to people's health and safety were assessed. Staff had access to information about how to manage and mitigate people's identified risks, to support them in a safe way.

People were protected from avoidable harm and abuse. The home had effective safeguarding policies and processes in place.

Staff were safely recruited and there was enough staff on duty to meet people’s needs in a timely way. Many staff members were long standing and were familiar with people’s needs. People and staff told us they thought of the home as ‘one big family.’

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 and were followed by the provider in line with the Mental Capacity Act.

Some management systems to identify and manage risks to the quality of the service required strengthening.

We have made a recommendation about further developing governance and performance management.

We received positive feedback about the management team from people, their relatives and staff.

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 21 July 2017).

Why we inspected

This inspection was prompted by the age of the last rating. As we had received no concerning information about the service, we carried out an inspection of the key questions of Safe and Well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. We have found evidence that the provider needs to make improvements. Please see the well-led section of this full report.

The overall rating for the service has remained Good based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Elm House Nursing 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.