Elmwood Residential Home Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We identified 1 breach of the legal regulations. Current governance arrangements were not effective. Medicines audits were not being completed and therefore not identifying issues. Auditing around care delivery was not fully protecting people and the provider had not effective way to audit the environment and monitor fire safety. This was a continued breach from the last inspection. However, despite the concerns identified in governance, we received very positive feedback from people and their relatives about the management of the service. The staff team told us the arrival of the registered manager had a very positive impact on staff culture, morale and overall atmosphere.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff we spoke with felt they were involved in the vision and values of the service and spoke very positively about the service management now in place. Staff felt part of the wider team and spoke of a great working environment and atmosphere, which was seen in our observations. One staff member said, “We know we feel we can go to [deputy manager] and [registered manager] and that is a comfort.”

There were process to involve staff in the service development. Staff told us that meetings were held where they could contribute ideas and suggestions. The provider and registered manager had a service improvement plan in place to drive improvement. The service management and staff actively sought the views of people and their families through surveys and meetings.

The registered manager was also the registered manager of a second service operated by the provider and split their time between the 2 services. The service had an experienced deputy manager and the provider was available for staff. All of the feedback we received from staff about the service leadership was positive. All comments from staff were positive about the improvements to the culture the service the registered manager had made. One staff member said, “I think the staff team get on well and it is a nice atmosphere and everyone is working hard and really friendly.”

Service leaders had created clear lines of responsibility and staff understood their roles. The provider, registered manager and deputy manager were visible for staff. There were processes for staff to feed in ideas and suggestions to help improve outcomes for people. There were systems in operation that identified poor culture or practice and this was addressed in line with the providers policies and process.

Staff told us that the service leadership was approachable and they would happily raise concerns or suggestions. People were supported by a staff team that were positive and wanted to achieve excellent outcomes for people. Staff and the service management were observed happy working together to make the day better. We observed staff to be working well together, planning, and supporting each other with their daily responsibilities. Staff told us they worked well as a team and that changes in the service management had promoted this.

There were whistleblowing policies in place and staff meetings were held for staff at all levels to seek feedback and communicate key messages. There were policies in place relating to the Duty of Candour detailing the providers responsibilities in the event something goes wrong.

Staff told us that the service management and the provider treated them well and they felt they got all the support and guidance they needed from them. Feedback was positive about all aspects of their employment, for example the staff numbers deployed by the service and the training available. One said, “I worked with previous manager and [registered manager] is quite nice and she has changed it a lot. [Registered manager] has improved things and I feel she had given the residents more choice and more activities and more staff and more domestic staff.”

The service management has processes that ensured there were effective and proactive ways to engage with and involve staff, with a focus on hearing the voices of staff. This included regular staff meetings and having an open door policy where staff felt confident that their concerns and ideas would be heard. Regular supervision was also held with staff where performance was discussed but was also an opportunity for staff to raise concerns and ideas. Staff were proud of the service they worked in and their ability to work as a team.

People and their relatives were complimentary about the leadership of the service. They were confident and knew who the management staff were and who to contact should they need to. People and their relatives were happy and comfortable to speak to any of the staff. The registered manager told us they were in the process of embedding a new governance structure and following the assessment CQC were sent a list of the new audits that were going to be completed by the service going forward. Whilst the feedback we received about the service management was positive, we identified shortfalls in the governance arrangements in place.

There were insufficient governance arrangements in place for the provider and registered manager to have full oversight of the health, safety and welfare of people using the service and others. The concerns we identified during the assessment had not been identified through effective governance and oversight. For example, no routine medicine audits were completed, there was no infection control audit in place, fire safety concerns had not been prioritised and health cand safety audits were not effective. There was no effective auditing system in place to monitor people’s care records to ensure staff had completed records accurately. No systems were in place to monitor weight management and air mattresses were not always being operated safely dure to the absence of oversight. During the assessment, we identified the service had failed to send statutory notifications to CQC as required by law. We use this information to monitor the service and ensure they respond appropriately to keep people safe and the absence of reported data may not ensure effective regulation can take place.

People received care from a service that worked in partnership with other health and social care professionals to achieve good outcomes for them. When we spoke with people and their relatives, no concerns were raised about access to other health professionals.

The service manager told us they worked with a number of other professionals and that they received the required level of support and guidance where required. They spoke positively about working relationships and how this had a benefit on people living at Elmwood Residential Home. Staff we spoke with explained how they escalated concerns to service management when referrals to external professionals is required.

The feedback we received from healthcare professions was varied. We received mainly positive feedback from all of the professionals we contacted. One comment we received was, “The management are handling a current safeguarding investigation with utmost professionalism. They have the resident at the centre of every communication and show her respect and dignity. I have witnessed the managers supporting her communication by allowing extra time to process spoken information and leaving silent space for her to respond.” Some concerns were however raised about the completion of documentation relating to people’s needs which we identified at the assessment.

There were processes in place to work in partnership with other healthcare professionals to escalate concerns or risk to people as required. We saw from records and feedback that working relationships were in place with the local district nursing team, GPs, Speech and Language Therapists, social workers and the safeguarding team.

The provider and registered manager had a service improvement plan that they told us what used to continually identify and grow the service. The provider, registered manager and deputy manager worked together on driving improvement. However, we found that insufficient improvements had been made since the last inspection and the service remained in breach of regulations. Staff we spoke with were clear with their responsibilities to learn from accidents and incidents and were able to communicate reporting processes. One said, “We have regular staff meetings and we can raise any concerns and we will talk about things that have gone wrong and if I was involved in an incident or any near misses. All incidents would be documented and we would have meetings so we can do a reflective essay if we choose to. We would discuss why it happened and what we can do to prevent it from happening again.”

The current processes in place for governance and auditing used by the provider and registered manager were not fully effective. Whilst we found there was a system to investigate and learn from complaints, the current system to monitor risk to people’s health safety and welfare placed them at risk. The registered manager told us that whilst not recorded, they had identified staff recording keeping was not always consistent or accurate and that this had been highlighted during staff meetings. However, it was evident that improvement had not been fully achieved from the findings of this assessment.