Elm Tree House

Updated 15 March 2023

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

One inspector carried out this inspection.

Service and service type

Elm Tree House 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 Tree House is a care home without 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 a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection. We used all this information to plan our inspection.

During the inspection

We looked at a variety of records relating to people’s personal care and support and the running of the service. These included, 4 people’s records in relation to their care and support, 4 people’s medicines records, 3 staff recruitment files and a variety of records relating to the management of the service including policies and procedures. We spoke with 4 members of staff including the registered manager. We spoke with 6 people and 1 visiting relative about their experience of the care provided.

Following the site visit we received feedback from 2 professionals who work with the service and spoke to a further 6 members of staff and 1 relative over the telephone.

Updated 15 March 2023

About the service

Elm Tree House is a residential care home providing personal care to up to 9 people. The service provides support to people living with mental health difficulties. At the time of our inspection there were 8 people using the service.

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

Risks to people were not always properly assessed to protect them from avoidable harm. Not all environmental risks for people using the service were safe, ensuring their safety, comfort and wellbeing. The registered manager was responsive to our feedback and took action to address the issues identified.

People's risk assessments were not always accurate and did not always provide staff with the information they required to safely meet people's needs. They were not always reviewed and updated following accidents and incidents.

Recruitment procedures were not always robust, and concerns were raised regarding staffing levels.

Peoples medicines were mostly administered safely by staff, although best practice guidance was not always being followed in relation to a clinical task delegated by a health professional.

The governance system had failed to identify the areas for improvement that we found during the inspection. The provider was responsive to address the shortfalls found within this inspection and took immediate action.

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.

People told us they felt safe and liked living at Elm Tree House. Staff supported people in a kind and compassionate way, considering their dignity and respecting people's rights. Throughout the inspection we observed kind, relaxed, compassionate and caring interactions between people and staff.

Infection control procedures and measures were in place to protect people from infection control risks.

Staff understood how to protect people from poor care and abuse. Staff had training on how to recognise and report abuse and they knew how to apply it.

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 17 October 2017)

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

Enforcement

We have identified breaches in relation to safe care and treatment and the management of the service at this inspection. We have also made recommendations in relation to medicines and staffing.

Please see the action we have told the provider to take at the end of this report.

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 work alongside the provider to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.