Elmhurst Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for the newly registered provider of this service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm. There was an increased risk that people could be harmed. The service was in breach of legal regulations in relation to risk management, medicines, safe systems and pathways, safeguarding, staffing and learning culture.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have proactive and positive cultures of safety based on openness and honesty. They did not always fully investigate safety events and lessons were not learnt to continually identify and embed good practice. Some relatives told us when they had reported concerns or made requests for improvement with the care provided, they were not listened or responded to. Records did not show there was a proactive culture in place regarding safety incidents or concerns. Events had not been effectively and robustly reflected upon and used to drive improvement.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. On some occasions the provider had been obstructive when other professionals had attended to assess the needs of a person and had misled them on the person’s needs. We reviewed the service’s pre-admission policy and found the service had failed to follow and implement the policy prior to admitting 1 person into the service. This meant a thorough pre-assessment was not completed with the person to ensure and demonstrate the service could meet this persons’ needs. Staff told us they did not know the person well and confirmed there was no care plan in place for this person.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. Records showed whilst some concerns of a safeguarding nature had been raised with the local authority as required, injuries that should have been reported to CQC had not. This meant the service failed to ensure all appropriate action was taken to fully protect people and failed to fulfil their legal obligations. We observed choices were made for people with no record of the discussion or decision-making process. In some instances, choices and preferences were stated to be of the person’s, however, the people in question had been assessed to not have capacity to make these decisions about their care. Staff feedback stated they were not safeguarding people due to a closed culture and pressure to conform to an institutionalised practice in the service, and did not feel they could report concerns openly or challenge poor practice and decision making with leaders.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Some people and relatives told us they felt the service was safe, however some relatives told us they did not feel their family member was always kept safe. They provided examples of when their relative had their choices and preferences removed creating an unsafe environment for them. Our observations showed staff knew people well however, risks were not being well managed for people in the service. We observed incorrect use of a wheelchair by staff, and a lack of staff supervision for one person when in communal areas, despite incident reports stating this was required. Records were not contemporaneous and failed to demonstrate how risks to people were being effectively managed. Despite some people having an assessed risk of pressure damage, repositioning records were not being monitored and contained large gaps, which meant people were at an increased risk of harm.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, and facilities supported the delivery of safe care. Records showed not all environmental risks in the service had been fully identified, recorded and mitigated. For example, we found risk assessments for the use of the stairs and stair lift had not been assessed for each person who used them daily. We also found risks associated with fire in people’s bedrooms had not been fully or robustly recorded or mitigated. This was in relation to the use of and storage of emollient creams in people’s bedrooms and bathrooms. Fire safety records showed fire evacuations and alarm testing was not completed in line with good practice for fire regulation. Personal emergency evacuation plans were not accurate for all people in the service and had not been reviewed. Some action was taken by the provider following our initial inspection feedback, however shortfalls in this area remained. The environment was not dementia friendly, with multiple bedroom doors being undistinguishable due to not having names, numbers or pictures on them.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and training. They did not work together well to provide safe care that met people’s individual needs. Records showed the recruitment process was not safe and the provider had failed to follow and implement their own recruitment policy. The provider had a staff training matrix in place, but this was not accurate or up to date and had failed to include 5 new staff members. Some staff had not had training in some of the mandatory subjects such as moving and handling which placed people at risk of harm. Most people and relatives told us overall they felt the service needed more staff, as there were not enough staff readily available to support people or engage in activities .

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. Whilst the service had not assessed the risk of infection for each person who used the service, most people we spoke with did not have concerns in relation infection management. We observed staff wore the correct personal protective equipment at appropriate times. Records showed daily cleaning of all areas of the home was completed routinely, inclusive of all bedrooms and bathrooms. However, we found areas of the home had strong malodours and the service only had 1 domestic staff member. This meant care staff were also responsible for cleaning tasks. Despite records showing this was occurring, we were not assured of this based on our observations during the assessment.

The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. People did not always have their medicines administered safely or at the right times either because the prescribers’ and manufacturers’ directions were not followed or because there was a delay in obtaining newly prescribed medicines. When people were prescribed medicines to be taken ‘when required’ or with a choice of dose, the protocols to support their administration were not detailed enough to ensure they were administered safely and consistently. Some people needed to be given their medicines covertly, by hiding the medicines in food or drinks, but there was no information from a healthcare professional about how to do this safely. When people were prescribed thickener to be added to their fluids, to help them swallow the fluids safely, we found no records were made about how much thickener should be or was used. The records about creams were not always accurate and there were no body maps for staff to follow when applying creams. Creams were not stored safely. We found no evidence that people were harmed at the time of the assessment because the harm is not always immediate. However, people were placed at increased risk of harm by not managing medicines safely.