Elm Park Care Home

Updated 27 April 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 was carried out by two inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of service.

Service and service type

Elm Park 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 Park is a care home with 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 inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. 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.

During the inspection

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We spoke with six people who used the service and 14 relatives about their experience of the care provided. We spoke with eight staff, including the registered manager, care staff and ancillary staff. We also contacted staff via email to obtain feedback and received six responses.

After the inspection

We continued to seek clarification from the provider to validate evidence found including training data and quality assurance records.

Updated 27 April 2022

About the service

Elm Park is a purpose built care home on the outskirts of Doncaster. The home provides accommodation for up to 100 people. At the time of our inspection there were 90 people using the service. The home provides residential and nursing care; this includes a dedicated unit on the first floor for people living with dementia.

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

Systems in place to monitor the service were not always effective. Audits in place had not always identified the concerns we initially found on inspection. Although concerns raised were swiftly addressed, new systems and approaches required embedding in to practice.

The management team and staff knew their roles and responsibilities. People and their relatives were complimentary about the home. The provider and registered manager used feedback to improve the service.

On the first day of inspection we found some areas of the home were in need of a deep clean. On the second day of inspection we found the service was clean and tidy. Appropriate action had been swiftly taken by the registered manager, who could demonstrate systems had been put in place to keep the home clean and well maintained.

The provider had systems in place to ensure people received their medications as prescribed. Some minor issues identified on the first day of our inspection were swiftly addressed by the registered manager.

The provider had a dependency tool which was used to identify the number of staff required each day. We found there were enough staff available to meet people’s needs in a timely way. The provider had a safe recruitment procedure to ensure appropriate staff were employed.

Accidents and incidents were recorded and analysed to identify any trends or patterns. This helped to mitigate future risks and ensured lessons were learnt. Risks associated with people's care had been identified and plans were in place to mitigate risks.

Staff were knowledgeable about safeguarding and confirmed they had received training in this subject. They knew what actions to take if they suspected abuse.

People's needs were assessed, and care was delivered in line with current legislation. We observed care and support being delivered in line with people's assessed needs and choices.

People were supported to maintain a healthy and balanced diet. We observed lunch being served and found people were assisted with making choices about what to eat. Through our observations, and speaking with staff, we found they had the skills to carry out their role. We found people had been referred to appropriate professionals when required, to ensure their needs were met.

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.

We observed staff interacting with people and found they were kind, caring and delivered support in a person-centred way. Relatives told us they were happy with the care their family member received and felt they were treated with dignity and respect.

Care plans were person centred and offered staff guidance about how to support people. Staff knew people well and assisted people to maintain their independence. Social activities were provided in line with people's interests and preferences.

Relatives we spoke with found the registered manager approachable and felt she would act on any complaints raised.

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

Rating at last inspection

This service was registered with us on 04 November 2019 and this is the first rated inspection. We also carried out an inspection looking at infection control. This inspection report was published on 26 November 2020, but the service was not rated at this time.

Why we inspected

We carried out this inspection in line with our current methodology.

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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Elm Park 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.