The Elms Care Home

At the time of our assessment the provider was in the process of amending their registration to a care home without nursing.

The provider was in breach of 3 legal regulations related to safe care and treatment, safeguarding people from abuse and good governance of the service,

People were not always protected in the event of a fire as some fire doors would not be effective in the event of a fire. The provider was in the process of changing the doors during the inspection. Following the inspection the provider confirmed actions were being taken to address the fire safety shortfalls. People were not always protected from the spread of infection as staff did not always follow the providers’ infection control processes. Staff did not always use safe manual handling techniques in line with the providers’ procedures, this placed people at risk of harm.

People were not always safeguarded from abuse, we found people did not always have their food prepared in line with their assessed needs. Staff lacked the sufficient understanding of how people required their meals prepared to manage the risk of choking and dysphagia. This placed people at risk of choking. People who had the capacity to make decisions for themselves were not free to leave the service independently, they had to ask staff to open the door which impacted on their freedom of movement.

People’s care plans were not always sufficiently detailed or robust to ensure staff had all the information they required to safely meet their needs and some contained contradictory information. This meant people were at risk of not receiving the care they required to meet their needs.

Staff had completed a mixture of online and face to face training, however staff were not always able to demonstrate they had the correct knowledge and skills to support people safely. We were not assured that people’s needs were met in a timely way due to delays in responding to call bells. The provider’s quality and risk monitoring systems had failed to identify all the shortfalls we identified during our inspection therefore action had not been taken to reduce all risks to people. When we made the provider aware of these shortfalls, they took immediate action to keep people safe and put new systems in place to address the shortfalls. Time was needed before we could judge the effectiveness of these newly introduced systems.

We identified areas of good practice during our assessment, these included robust systems to monitor any accidents and incidents, including actions taken to mitigate risk and any lessons learnt and good oversight of servicing of equipment. The provider had recently employed a new deputy manager, home manager and operations manager, who all demonstrated they were passionate, dedicated and had recently identified some of the shortfalls we found during the assessment, there was an action plan in place however the required improvements had not been embedded at the time of our inspection.

We have asked the provider for an action plan in response to the concerns found at this assessment.