Elm Lodge Care Home

Updated 11 October 2022

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.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team included two inspectors and an Expert by Experience (ExE). An ExE is a person who has personal experienced of using a care home or caring for someone who uses this type of care service.

Service and service type

Elm Lodge Care Home, 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 Lodge Care Home 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 service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. 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. This included 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 also sought feedback from the local authority and professionals who work with the service. We used this information to plan our inspection.

During the inspection

We spoke with four people who used the service, eight relatives, three care staff, a cook, a domestic, the registered manager, deputy manager and nominated individual for the provider. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We observed how staff interacted with people and we reviewed a range of records. This included six people's care plans, multiple medicines records; staffing and quality assurance management records, and a range of the provider’s operational policies. Following the inspection, we continued to seek clarification from the provider, to validate evidence found.

Updated 11 October 2022

Elm Lodge Care Home is a residential care home providing personal care for up to 46 adults. Including people who may be living with dementia. At the time of our inspection there were 41 people using the service and two in hospital. Accessible, single room accommodation is provided within purpose built accommodation, which includes a range of communal living, bathing and toilet facilities, along with level access to a well kept garden and visitor parking.

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

We were assured the provider was meeting with requirements and nationally recognised government guidance, concerned with the prevention and control of infection, including COVID-19.

People were protected from the risk of harm or abuse within the service. Effective risk management strategies were operated for people's care and related safety needs.

Staff understood people’s individual, risk assessed needs and supported people safely when they provided care. People’s medicines were safely managed, and people received their medicines when they should.

People were supported to have maximum choice and control of their lives. The provider was able to demonstrate that decisions made for people's care and daily living arrangements were lawful, least restrictive and in people's best interests.

Staff were safely recruited, deployed and understood their role and responsibilities for people’s care and safety.

The provider was now able to demonstrate fully embedded and continuous service improvement through effective governance arrangements.

There was a registered manager for the service who understood the requirements of their role. Overall, people, relatives and staff were confident in the management of the service. All were regularly consulted to inform people’s care and the provider’s related service planning and improvement.

Effective partnership working with relevant external professionals and authorities was now demonstrated as fully embedded and sustained for people’s care.

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

The last rating for this service was requires improvement (published 7 September 2019). The provider completed an action plan following the last inspection, to show what they would do and by when to improve. At this inspection we found improvements had been made in the areas we inspected to Good [Safe and Well Led]. The overall service rating remains requires improvement.

Why we inspected

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.

This was a focused inspection prompted by a review of the information we held about this service, including concerns we received. This report only covers our findings in relation to the Key Questions Safe and Well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Elm Lodge Care Home on our website at www.cqc.org.uk

Follow up

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