Elmwood Care Home

Updated 24 February 2022

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to care homes with outbreaks of COVID-19, we are conducting reviews to ensure that the Infection Prevention and Control (IPC) practice is safe and that services are compliant with IPC measures. This was a targeted inspection triggered by an outbreak of COVID-19 to look at the IPC practices the provider has in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

This inspection took place on 20 January 2022 and was announced.

Updated 24 February 2022

This was an unannounced inspection carried out on 27 June and 6 July 2017. At the last inspection in May 2016 we rated the home as requires improvement. At the last inspection the service was in breach of one regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 9, Person-centred care. At this inspection we found the provider was no longer in breach of the previously identified regulation and they had made significant improvements to the service and the care people received.

Elmwood Care Home is situated in the Oakwood area of Leeds. The home has 36 beds, providing accommodation and nursing care for older people and people living with dementia. There were 25 people living at the service at the time of inspection.

There was a registered manager in post. 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 told us they felt safe in their home. There were enough staff to deliver care safely, and staff received appropriate training and support. Staff had a good understanding of the signs of abuse and how to safeguard vulnerable adults and report concerns.

Overall medicines were managed safely; however we have made a recommendation about the management of some medicines.

Maintenance and premises safety checks had been falsely completed. This meant we could not be sure equipment was safe. The manager completed the checks robustly and confirmed safety. The manager told us they were investigating how this had happened to prevent a future reoccurrence.

There were appropriate recruitment processes in place to ensure staff were recruited safely and that they were suitable to work with vulnerable adults.

There were policies and procedures in place in relation to the Mental Capacity Act (MCA) 2005. Staff were trained in the principles of the MCA and could describe how people were supported to make decisions; and where people did not have the capacity; decisions were made in their best interests.

We saw that people received support from kind and compassionate staff who understood their individual needs. Care plans were person centred and there was evidence of involvement from people and their relatives. People had plans in place to manage risks which were understood by staff.

People were supported to eat and drink safely and they told us they were able to choose what they wanted. If people did not like the options, kitchen staff were able to prepare alternatives from a well-stocked pantry containing fresh produce and ingredients. People’s weight was monitored and nutritional risk assessed appropriately.

People had regular and appropriate access to health professionals, and staff worked in partnership with health professionals to help people maintain their clinical wellbeing and manage their care needs.

There were systems in place for people to complain, and we saw evidence that complaints were responded to in line with the provider policy in a timely and appropriate way.

There was a clear leadership structure with the manager holding oversight of governance arrangements. Staff understood their roles and what was expected of them.

We saw that there was an effective quality assurance process, with a range of audits and monitoring systems in place to ensure quality of care was maintained and the environment of the home was safe.

We saw that the provider asked people what they thought of the service and that their views had generated actions to be taken by staff to make improvements.