Elmwood Residential Home Limited

Elmwood Residential Home Limited is a large detached period property in the town of Colyton in Devon with a large landscaped garden which people can easily access. It located 3 miles from Seaton and 6 miles from Axminster. They are registered to provide accommodation with personal care for up to 38 people with physical disabilities, long term medical conditions or memory loss. At the time of our inspection there were 34 people using the service.

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

People and relatives felt the service was safe. Comments included, “They look after us well. I haven’t got any complaints at all” and “I feel secure. I’m not afraid.”

People’s medicines were not always safely managed in line with the provider’s policy. We have made a recommendation about the management of medicines.

Staff had completed the providers mandatory training, but they had not always had their competency assessed and received refresher training. Staff had received safeguarding training and were aware of the different types of abuse.

Risk management was not always robust. In particular, monitoring people’s individual risks in relation to skin integrity and nutritional status. The management team needed to resume their monitoring of accidents and incidents to ensure staff had taken appropriate action and to look at any potential trends and minimise the risk of future incidents.

Fire safety and environmental safety needed to be improved to keep people safe. The provider took action at the inspection to reduce the risks to people.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The provider increased the staffing levels at night during the inspection. They told us the dependency tool they used to assess staff levels was being reviewed. Recruitment processes were robust.

The registered manager had resigned her position and left the home in October 2022 and had applied to deregister with CQC. The deputy manager had stepped into the managers role while the provider tried to recruit a new manager. At the time of the inspection the registered manager had returned to the home to cover while the deputy manager took a period of planned leave. The registered manager deregistered with CQC on 19 December 2022.

Since the registered manager had left in October 2022, managerial oversight had fallen behind at the home. This meant opportunities to drive positive change might have been missed, which could have resulted in improvement in the outcomes for people and reduce incidents.

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

Rating at last inspection for this service was good (published 3 November 2018).

Why we inspected

We received concerns in relation to the management at the service and concerns raised by visiting health care professionals. As a result, we undertook a focused inspection to review the key questions of safe, effective and well led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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

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

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 continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

The home was clean and free from odours. Housekeeping staff completed cleaning schedules and frequent cleaning of regularly touched surfaces was implemented.

The provider had a regular programme of COVID-19 testing for people in the home, staff, and visitors. All visitors, including professionals, were subject to a range of screening procedures, including showing evidence of vaccination and a negative lateral flow test before entry into the home was allowed. The provider had installed a shelter outside of the main front door to facilitate these checks.

Visits with relatives and friends were accommodated and adaptations made in response to the changing government guidelines. Two rooms had been adapted which were accessed from the garden through french doors. Each room had a screen, comfortable seating, PPE and handwashing facilities. The rooms were bright and had an intercom to improve communication. The registered manager told us visitors were asking to use these rooms even though they did not have a Covid-19 outbreak at the home.

The providers infection prevention and control policy was regularly reviewed and updated to ensure it was appropriate and in line with current guidance. There were regular cleaning audits and the provider shared with us a robust infection control audit they had completed in February 2022 which was reviewed every three months.

The provider ensured enough stock of appropriate protective equipment (PPE) was available for people, staff and visitors. Staff confirmed there was always plenty of PPE available.

Staff continued to support people to access health services. Arrangements were in place to ensure people remained safe if they required a hospital admission.

Workforce pressures were not having a detrimental impact on the delivery of the service.

Elmwood residential home is registered to provide accommodation with personal care for up to 38 people with physical disabilities, long term medical conditions or memory loss. 37 people lived there when we visited.

At the previous inspection on the 13 and 14 September 2017, the service was rated as requires improvement overall, with the safe, effective, responsive and well led domains rated requires improvement and the caring domain rated as good. Four breaches of regulations were found in safe care and treatment, safeguarding, quality monitoring and in relation to a failure to notify the commission about an allegation of abuse. Following the inspection, CQC took further enforcement action by imposing a condition on the provider’s registration. This was because the service had been rated requires improvement with breaches of regulations for the fourth successive inspection. The condition required the provider to provide CQC with a monthly report to demonstrate they were making the required improvements at the service.

CQC met with the provider on 10 January 2018. The purpose of the meeting was to ensure the provider was clear that CQC's expected improvement at the next inspection, with no breaches of regulations. We also emphasised the need to ensure these improvements were sustained. Since December 2017, the service has sent monthly reports, which have included examples of continuous improvements.

Since then, the service has worked closely with the local authority, their quality assurance improvement team and the Care Quality Commission to make the required improvements. The local authority quality assurance and improvement team has visited the service regularly to support the provider to continuously improve their quality monitoring systems. Joint meetings were held with the provider, local authority and care manager to monitor progress and ensure continuous improvements were made. At this inspection, significant improvements had been made in the provider’s quality monitoring systems. People's care records had improved, care plans, risk assessments and daily records were more detailed, and personalised. However, further improvements were still needed to make sure staff had the training and sufficient equipment to use electronic care records effectively.

The provider, registered manager and deputy manager, worked well together. People, relatives, staff and professionals gave us positive feedback about the quality of people’s care. They spoke about improvements in communication, professional development and improved quality monitoring systems.

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.

People were protected from abuse because the leadership team had completed additional safeguarding training with the local authority. They demonstrated a good understanding of their responsibilities to report safeguarding concerns, and worked in partnership with other agencies, where concerns about abuse were identified. The service informed the local authority safeguarding team about suspected abuse and notified the Care Quality Commission (CQC). Where concerns about staff practice were identified, they were robustly dealt with through additional training, supervision, and if needed, by following the provider’s disciplinary procedures.

Staff demonstrated a good awareness of each person's safety and how to minimise risks for them. Improvements had been made in the garden to improve people’s access and reduce their risks of slips trips and falls. All hazardous chemicals were safely stored when not in use in accordance with health and safety regulations. People's risk assessments were comprehensive with actions taken to reduce the risks as much as possible. Regular health and safety checks were carried out with improvements made in response.

People received their medicines safely and on time. Robust recruitment processes were in place to ensure staff employed were suitable to work with people. People were protected from cross infection by regular cleaning, handwashing and good infection control systems.

People were supported by staff that were caring, compassionate and treated them with dignity and respect. Where concerns or complaints were raised, they were listened and responded to and used as opportunities to improve.

People were supported by staff who had the skills and knowledge to meet their needs. Staff had a better understanding of their responsibilities and felt more confident to carry out their roles. People’s health was improved by staff who worked with a range of professionals to access healthcare services. People praised the quality of food, and staff promoted people to improve their health through good nutrition and hydration.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS provide legal protection for those vulnerable people who are, or may become, deprived of their liberty.

The service was well led, with no breaches of regulations at this inspection. CQC is satisfied the provider has made the required improvements in quality monitoring and has decided to remove the monthly reporting condition from the provider’s registration.

Further information is in the detailed findings below.

This unannounced comprehensive inspection took place on 13 and 14 September 2017. This inspection was to follow up to see whether improvements had been made from the previous inspection in January 2017.

At the previous focused inspection on 25 January 2017 the service was rated as requires improvement overall, with responsive and well led rated requires improvement and safe rated as good. We did not inspect effective and caring domains at the inspection. Two breaches of regulations were found in relation to good governance and in response to complaints. Although some aspects of quality monitoring had improved since our previous inspection in August 2016, it was still not fully effective. This was because of some gaps in people’s care plans and daily records and because some complaints had not been robustly dealt with. Following the January 2017 inspection the Care Quality Commission (CQC) took enforcement action and served a warning notice in relation to good governance. This required the provider to make the required improvements by the 10 July 2017. In response, the provider submitted an improvement action plan.

Following this inspection in September 2017, we have now rated the service as ‘requires improvement’ overall on four successive inspections. A breach of regulation 17, good governance, has been identified at the last three inspections. This demonstrates the providers' quality monitoring systems were still not effective and they have not fully complied with the warning notice.

Previously on 2 and 3 August 2016 a comprehensive inspection rated the service as requires improvement. This was because we found two breaches of regulations in relation to people’s safe care and treatment and good governance. Prior to that, on 21 and 28 April 2015, a comprehensive inspection rated the service as requires improvement overall, with three breach of regulations relating to person centred care, consent and safe care and treatment.

On 12 April 2017 we met the provider and the registered manager and set CQC’s expectations that at the next inspection, all required improvements should have been completed with no breaches of regulations. We also emphasised the need to ensure these improvements were sustained over time. The service was also working with the local authority quality monitoring team to make the required improvements.

At our meeting on 12 April 2017 we asked the service to consider whether having the registered manager who also undertook the nominated individual (providers representative) role was the most effective way to monitor quality at the home. In response, the provider notified us that a director in the company was taking on this role. Since June 2017, a director has been based at the home.

The service has a registered manager in place. 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.

The service had worked with the local authority quality improvement team to make improvements. They quality improvement team last visited the service in March 2017. Their report showed the service were making progress with improved quality monitoring systems, with further improvements needed in communication, direction and leadership.

At this inspection, improvements in some aspects of the quality monitoring systems had been made. However, the provider had failed to identify two new breaches of regulations and we found several areas for improvement. One breach related to the safe care and treatment regulation. The provider had previously complied with this regulation at the January 2017 inspection. However, this inspection found a breach in this regulation again. This showed the provider had failed to sustain the improvement.

People were not fully protected because a concern about suspected abuse had not been reported to the local authority or the CQC. The provider and registered manager did not demonstrate they understood their responsibilities for safeguarding. They failed to follow their own policy and procedures in responding to a suspected abuse incident. Staff understanding and knowledge about their safeguarding responsibilities also varied.

People were at increased risk because some environmental risks were not adequately managed. We found hazards due to contractors working in the home and some garden areas were not adequately maintained. Hazardous chemicals were not stored in line with the provider’s risk assessments, legislation and guidance.

People received healthcare that met their needs. Staff had undertaken training on the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. However, the arrangements for the care of a person who lacked capacity, did not demonstrate staff had considered the least restrictive options for their care.

People’s care records had improved and individual risk assessments were well completed with actions taken to reduce risk. People and relatives said staff consulted them about any decisions needed, although this was not clearly captured in people’s care plans. However, other correspondence between the service and people’s families demonstrated this. Further improvements were needed in relation to accuracy and secure storage to protect people’s confidentiality.

Improvements had been made in responding to complaints. People knew how to raise concerns and complaints, and were provided with information about how to do so. Any concerns raised were robustly dealt with.

People received their medicines on time from staff that were trained and assessed to manage medicines safely. However, improvements were needed in relation to prescribed creams and ointments and documenting when people declined their medicines. A detailed recruitment process was in place to ensure people were cared for by suitable staff.

People were well cared for by staff that had regular training to gain the knowledge and skills to support their care and treatment needs. People appeared happy and content in their surroundings, they were relaxed and comfortable with staff who knew people well and treated them with dignity and respect. People who received end of life care at the service were kept comfortable and pain free.

The service had enough staff to support people's care flexibly around their wishes and preferences. Improvements had been made in the variety of group and individual activities for people living at the home with an increased focus on one to one social contact.

People had access to healthcare services, staff recognised when a person's health deteriorated and sought medical advice promptly. People praised the quality of food and choices available. People were supported to improve their health through good nutrition and hydration. A new system had been introduced to identify to staff people that needed additional support with eating and drinking or were on special diets, which was working well.

Four breaches of regulation were identified at this inspection and the warning notice issued in March 2017 has not been met. CQC have taken further enforcement action by imposing a condition on the providers registration. This requires the provider to provide CQC with a monthly report outlining actions and progress in making the required improvements. We will inspect this service again within the next 12 months.

This inspection was to follow up if the required improvements had been made following our last inspection 2 and 3 Aug 2016. At that visit, we rated the service as ‘Requires improvement’, as we found two breaches of regulations in relation to people’s safe care and treatment and in good governance. We had previously visited the service 21 and 28 April 2016 and rated the service as ‘Requires Improvement’ because we identified breaches in both those regulations and in person centred care. Since the August 2016 inspection we received an action plan from the provider which outlined the improvements being made. The service has worked in partnership with the local authority quality assurance and improvement team to improve their systems and processes. They were using several new audit tools recommended by the local authority quality monitoring team.e met with two representatives of the provider on 9 January 2017 to discuss the improvements, which they said they had put in place.

This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (location's name) on our website at www.cqc.org.uk

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. When we visited, the registered manager was on planned sick leave. Prior to their absence, they had notified the Care Quality Commission and the deputy manager was in charge of the day to day running of the home.

At this visit we found some improvements had been made in the quality monitoring systems at the home. However, these were still not fully effective, because breaches of regulation were also identified at this inspection. People’s care records had improved. They were easier to navigate, information was accessible and older information had been removed and archived. People’s records had more individualised details about each person, their likes and dislikes, and about their life before they came to live at the home. Care plans and risks assessments had been reviewed and updated and were more comprehensive.

However, two people with diabetes had no care plans to guide staff about how to meet their specific health needs. For another person totally dependent on staff for food and drink, poor record keeping of their nutrition and hydration records increased the risk those needs were not being met. We also found other gaps in people's daily records and in activity records which had not been successfully addressed through audits undertaken.

We identified concerns with regard to how complaints about individual staff performance were managed. Where repeated concerns about some staff had been raised, they had not been robustly dealt with and recurred. People remained at risk because the service’s grievance and disciplinary policies about staff performance had not been followed and the audit of complaints should have picked up these issues and addressed them. We also found communication within the staff wasn’t effective in maintaining and embedding the improvements.

Health and safety risks for people were reduced because improvements had been made to the safety of the environment. People were protected from scalds because thermostatic controlled valves were fitted in all areas to ensure hot water temperatures remained within the recommended range. Balcony rails had been repaired and repainted and new window restrictors were fitted in rooms which previously didn’t have them, which reduced risks of people falling from the upper floors.

People were protected from potential abuse and avoidable harm. Staff had received safeguarding adults training and the provider had safeguarding and whistle blowing policies, so staff were clear how to report concerns.

People were supported by skilled staff that provided care at a time and pace convenient for each person. Improvements in medicines management had been made. The home was clean throughout, and odours were successfully managed. Monthly audits of cleanliness and infection control were carried out with actions taken in response to findings.

People and families said staff consulted and involved them in developing their care plan. People’s care records included more person centred details about people’s individual preferences about their life before they came to live at the home.

People enjoyed a range of individual and group activities. These included an exercise class, knit and natter group, quizzes bingo and movie night. External entertainment such as musical entertainment was arranged as well as trips to local places of interest.

People said they were happy living at the home and with the quality of care received. Residents meetings were held where the views of people were sought about the food, activity programme and about whether people had any concerns or grumbles.

Although improvements had been made, two breaches of regulations were identified at this inspection. CQC have taken enforcement action in relation to one of those breaches by serving a warning notice. We will carry out a further inspection within the next six months to check this has been met.

The service is registered to provide accommodation with personal care for up to 38 people. The home is mainly for people over 65 years of age, who may have physical disabilities, long term medical conditions or memory loss. There were 37 people at the service when we visited, one of whom was staying temporarily for a period of respite.

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.

At this inspection we identified several environmental risks for people who lived at Elmwood. These included scald risks due to excessively hot water, broken/missing window restrictors in some upstairs bedrooms, and balcony areas that appeared in a poor state of repair. We asked the registered manager to seek further advice to help them risk assess and prioritise what urgent actions were needed to improve people’s safety and reduce environmental risks for them. They updated us within a few days of the inspection, of actions underway to reduce risks and further work was planned.

Although some aspects of care records had improved, we found the standard of record keeping was inconsistent. Some people’s care records were up to date, there were gaps in other records and some were overdue for updating. This increased the risk people would not receive all the care they needed. People were not fully protected because the quality monitoring systems in place were not fully effective. This was because they did not identify the environmental risks or issues with records found during the inspection.

Staff had undertaken additional training and understood their responsibilities in relation to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS).

People had access to healthcare services for ongoing healthcare support. Staff recognised when a person's health deteriorated and sought medical advice promptly when they were feeling unwell. Staff worked closely with local healthcare professionals such as the GP and district nursing team, who confirmed staff sought advice appropriately about people's health needs and followed their advice. People received their prescribed medicines on time and in a safe way. People were supported to improve their health through good nutrition and staff encouraged people to eat a well-balanced diet, and make healthy eating choices.

Staff were knowledgeable about people's care needs and received regular relevant training and updating. Staff knew people well, understood their needs and care was personalised to their individual needs. Staff treated people with sensitivity, dignity and respect and in a caring and compassionate way. People were supported to keep in touch with family and friends and spend time with them.

Staff demonstrated a good understanding of what might constitute abuse and knew how to report any concerns they might have. The provider had a written complaints policy and procedure, and knew how to raise concerns or complaints, which were investigated and responded to.

The culture at the service was open, and promoted person centred values. Staff worked proactively with other professionals for the benefit of the people they supported. There was evidence of making improvements in response to people’s feedback, and of learning lessons following accidents and incidents.

We identified two breaches of regulations during the inspection. You can see what action we told the provider to take at the back of the full version of the report.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking to people using the service, staff supporting them and from looking at records. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People told us they felt safe at the home. Safeguarding procedures were robust and staff understood how to safeguard the people they supported. Systems were in place to make sure that the managers and staff learnt from events such as incidents, complaints, concerns and investigations. This reduced the risks to people and helped the service to continually improve. The home had policies and procedures in relation to the Mental Capacity Act 2005, and the Deprivation of Liberty Safeguards although no applications had needed to be submitted. Relevant staff had been trained to understand when an application should be made and how to submit one. This meant that people were safeguarded.

Care plans included considerations of the Mental Capacity Act (2005) such as best interest decision making and staff demonstrated an understanding of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DOLS) and how they applied to their practice. We found the location to be meeting the requirements of the Mental Capacity Act (2005). People's human rights were therefore properly recognised, respected and promoted and appropriate family/advocates were involved.

Recruitment practice was safe for example the Registered Manager asked for all background checks and references to be performed on staff prior to an offer of employment being made. No staff had been subject to a disciplinary action. Policies and procedures were in place to make sure that unsafe practice was identified and people were protected.

Is the service effective?

People's healthcare needs were assessed with them but they were not always involved in writing their care plans. Specialist dietary, mobility and equipment needs had been identified in care plans where required. Some people said they had been involved in writing them and said that care plans reflected their current needs.

Is the service caring?

People were supported by kind and attentive staff. We saw that care staff showed patience and gave encouragement when supporting people. One person told us, 'The staff are very helpful. They listen to me and do what I ask them to do. I am quite particular with my personal care and the staff help me to maintain as much of my independence as possible and my dignity'. People were treated with dignity and respect by the staff.

People's preferences, interests, aspirations and diverse needs had been recorded and care support had been provided in accordance with people's wishes.

Is the service responsive?

People regularly completed a range of activities in the home. Most people enjoyed the entertainment and trips out. All people were offered the choice of outings but some declined.

The service responded well to peoples changing health care needs. The home had good working relationships with local GP's and district nursing teams and plans of care were well documented and person cantered.

People knew how to make a complaint if they were unhappy. No one we spoke to felt the need to make a complaint as they were very happy with the service they received. We looked at how complaints had been dealt with and found that the responses had been open, thorough and timely. People could therefore be assured that complaints were investigated and action was taken as necessary.

Is the service well-led?

The service worked well with other agencies and services to make sure that people received the best care that could be provided. The service had a quality assurance system that frequently asked for feedback from friends, family and people using the service to assess the quality of care being provided. Records seen by us showed that identified shortfalls had been addressed promptly. As a result the quality of the service was continually improving. Staff told us they were clear about their roles and responsibilities.

There were 36 people living in the home at the time of our inspection. People responded positively to visitors who came into the home to visit, provide professional support or voluntarily support them. The home was light and spacious and had a homely atmosphere.

The people we spoke with and their visitors were complimentary about the home and told us about how they were involved in deciding about their care treatment and support. We saw how people's care and welfare was provided with dignity and respect in line with their care plan.

The home was clean and homely and we saw how the manager worked with other professionals to ensure people received appropriate support and that their safety and welfare was protected.

Medication was managed in line with the providers policy and staffing levels, skills and experience were appropriate to meet the needs of people living in the home. Complaints were responded to in a timely way and the policy was promoted within the home and in the providers' brochure.