Archived: Elmwood House

Elmwood House is a nursing home providing personal and nursing care to up to 32 people. The service supports adults with learning disabilities, including autistic spectrum disorder, associated mental health and physical disability needs. The home is split into four living areas across three floors, with communal lounges and dining spaces. At the time of our inspection, 23 people were living at the service.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people, respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support:

People’s care records did not always provide up to date information on risk for staff to support them safely. People did not always have access to specialist health and social care support as staff were not always guided on when this was needed. Medicines were not managed appropriately which meant people were put at an unnecessary risk of harm.

Incidents and accidents were not always effectively recorded or monitored. This meant action to prevent further risk of incidents or accidents was not always identified. Governance arrangements were not always effective to fully ensure the quality and safety of people's care.

Best practice guidance in relation to restraint was not always followed. The service did not always record when staff restrained people and there was no monitoring of restraint within the service in order to learn from the use of restraint and consider how it could be reduced.

People were not always supported within a well-maintained and clean environment.

Right Care:

People's care records did not always promote their care being delivered in a dignified way. There were improvements needed to the language used by staff to ensure people were always treated with respect and dignity.

The service had enough staff to meet people’s needs.

Right Culture:

People were at risk of harm because of a lack of protection to prevent unnecessary restraint.

Staff did not have enough guidance to support people to manage their distress, anxiety, feelings and emotional reactions in a personalised way.

The management team were developing systems to improve the culture within the service, particularly to ensure documentation was completed to support people to achieve good outcomes.

The service enabled people and those important to them to be involved in their care planning. There were opportunities for people, relatives and staff to feedback on the running of the service.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 28 June 2022).

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about safety, infection control and management of the service. As a result, we planned a focused inspection to review the key questions of safe and well-led only. During our site visit we observed concerns which related to the key question of caring, therefore a decision was made to open up the key question of caring within this focused inspection.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, caring and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Elmwood House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safety, safeguarding, recruitment, dignity and governance at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Elmwood House is a care home providing personal and nursing care to 22 people at the time of the inspection. The service can support up to 32 people. The service is split into 4 different areas over 3 separate floors, the cottage, the lodge, the villa and the penthouse. People have access to communal lounges and dining spaces, as well as an outdoor area.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people, respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. 'Right support, right care, right culture' is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support:

Medicines were not managed safely, which meant people were put at an unnecessary risk of harm.

Accidents and incident management was not effective. The system to review accidents and incidents to ensure lessons were learned had not yet been embedded. There was no analysis of themes or trends to identify how risks to people could be mitigated. This meant any changes in people’s needs following accidents or incidents were not identified or reflected in their care records.

Since our last inspection, staff had worked with people to reduce the use of restraint. The service recorded when staff restrained people, and staff learned from those incidents and how they might be avoided or reduced.

People were supported to live in a clean environment.

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.

Right Care:

The majority of people’s care had been reviewed to ensure risks people might face were assessed. Where actions to mitigate risk were identified, staff did not always ensure this was carried out.

The service had enough appropriately skilled staff to meet people’s needs and keep them safe.

Right Culture:

People were not always supported to lead inclusive and empowered lives because of the ethos, values, attitudes and behaviours of the management and staff. Risks of a closed culture were not always identified so that people received support based on transparency, respect, and inclusivity. Records describing people or behaviour were not always written respectfully.

Feedback on the quality of support provided to people was sought, involving the person, their families, and other professionals as appropriate.

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

Rating at last inspection and update

The last rating for this service was inadequate (published 7 January 2023).

At this inspection we found the provider remained in breach of regulations.

Why we inspected

We received concerns in relation to the management of accidents and incidents at the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Elmwood House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment and governance at this inspection.

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

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any Key Question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Elmwood House is a residential care home providing nursing care to up to 32 adults with learning disabilities, including autistic spectrum disorder, associated mental health and physical disability needs. The home comprises of four distinct living areas, with named ‘houses’ across three floors. There is access to limited outdoor space. At the time of inspection there were 25 people were using the service.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. 'Right support, right care, right culture' is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it. Based on our review of Safe and Well Led the service was not able to fully demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture. Staff were focused on providing individualised care to people.

A range of improvements in the quality and safety of people’s care at the service, had either been made or were in progress since our last inspection. However, we found areas of continued risk to people’s safety in some the provider’s arrangements for people’s medicines, environmental cleanliness and infection prevention and control. We also found gaps in the provider’s governance arrangements, which were not always effective to fully ensure the quality and safety of people’s care, including proactive, timely and sustained service improvement when needed.

We found improvements in some of the provider’s risk management strategies for people’s care and safety. However, there were still gaps following significant incidents, where remedial actions to avoid repetition and demonstrate lessons learned, were not always ensured consistent or timely. Where service improvements had been made these were not yet demonstrated as fully embedded or sustained ongoing for people’s care and safety.

Staffing arrangements were now sufficient, safely recruited to and regularly reviewed. Staff supported people in the least restrictive way and any restrictions and related conditions were legally authorised and followed, when required.

People were included in discussions about the home through meetings. Staff demonstrated caring, responsive interactions with people they were supporting during the inspection. Feedback showed satisfaction with a range of service improvements since our last inspection but all parties felt this now needed to be demonstrated as ongoing, timely and sustained.

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

Rating at last inspection and update

The last rating for this service was inadequate (published 3 September 2021) and there were breaches. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

This service has been in Special Measures since September 2021. During this inspection the provider demonstrated that improvements have been made and the service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

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 to check the provider had followed their action plan following breaches we found at our last inspection of this service in June 2021, and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led, which contain those requirements. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. We found improvements had been made and the overall rating for the service has now changed from inadequate to requires improvement. This is based on the findings at this inspection.

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

Enforcement and Recommendations

Since the last inspection we recognised that the provider had failed to comply with a condition of registration imposing a restriction on admissions to the service. This was a breach of regulation and we issued a criminal offence fixed penalty notice. The provider accepted a fixed penalty and paid this in full

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Elmwood House is a residential care home providing personal and nursing care to 32 people. People living at the home had mental health support needs, learning disabilities, autism or physical disabilities. The home had four distinct living areas across three floors. It is a larger home which people move into to have additional nursing support.

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

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of Safe and Well Led the service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture. Although staff were focused on providing person centred care to people some of the governance systems didn’t ensure these values were embedded in the quality of the home. People were at risk because government guidance to implement infection control systems to reduce the risk of COVID-19 had not been fully implemented. The oversight and governance of people's care and treatment was not adequate to ensure they were able to live as healthy and independent life as they chose.

There were enough staff to meet people's needs promptly and some staff were skilled in supporting people in the least restrictive way identified. However, staffing levels were not regularly reviewed and the recruitment of new staff was not thorough enough. The guidance available for staff was not always detailed enough, reviewed regularly enough and for some circumstances such as certain medicines administration was not in place. This meant people were at an increased risk of harm.

People were included in discussions about the home through meetings and staff felt listened to. Other professionals reported good communication and relationships.

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 27 February 2018)

Why we inspected

The inspection was prompted in part due to concerns received about safeguarding and managing risk. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Good to Inadequate. We have found evidence that the provider needs to make improvement. Please see the Safe and Well led sections of this report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Elmwood House on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We have identified breaches in relation to safe care and treatment, safe recruitment of staff and good governance.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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 and local authority to monitor progress. We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We inspected this home on 2 February 18. At our last inspection we found the provider was meeting the regulations and we rated the home as ‘Good’ overall. However for the key section of caring we rated them as ‘Requires improvement’ and asked them to make improvements to achieve a minimum rating of ‘Good’. The care service supports people with learning disabilities and autism to support them to live as ordinary a life as any citizen. This service is delivered in a large complex and was registered with us before the introduction of ‘Building the Right Support and Registering the Right Support guidance.’ However the home aims to work towards the guidance with the values that underpin this practice.

These values include choice, promotion of independence and inclusion. Elmwood is in the village of Hollingwood. The accommodation is provided in a large building divided into four units. Each unit is independent with their own kitchen, living space and bedrooms. Elmwood accommodates 32 people, at the time of our inspection there were 31 people using the service.

The service had 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.

The provider had not always completed audits and those which had been completed had not been used to reflect trends and drive improvements. Peoples views had been considered, however a formal survey had not been completed or an improvement plan completed to reflect the direction of the home.

The home offered a homely atmosphere and people felt the management team were visible. There were sufficient staff to support people’s needs who were aware of how to keep them safe from harm. People had their risks assessed and measures taken to reduce any risks. The medicines were managed to meet peoples prescribed needs.

People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice. Health care professionals had been consulted and when guidance was provided this was implemented. People enjoyed the meals and had a choice which reflected their preference and dietary needs. Individual’s independence levels were promoted and life styles were being developed. People were protected from having sore skin and their weights had been monitored to ensure they received the required nutritional support to maintain good health.

Staff had established positive relationships which enabled them to personalise the care they delivered. Care plans were person centred and identified people’s preferences and their lifestyle choices. Information was offered in a range of methods, pictorial, visual and written. Other methods were being considered to supported understanding and choice. People and relatives all identified that staff offered respect and when they delivered care it was in a dignified way.

The home had a complaints procedure; however the home had not received any complaints since our last inspection. Staff felt supported in their role and had received training and inductions to enhance their skills. When staff joined the home they were checked to ensure they were suitable to work with people.

The registered manager understood their registration and had notified us of events. They had displayed the previous rating in the home and on the provider’s website. We saw that the previous rating was displayed in the reception of the home as required. The manager understood their responsibility of registration with us and notified us of important events that occurred at the service; this meant we could check appropriate action had been taken.

We found the environment was not fully safe and that effective systems were not in place to monitor the quality of care provided. Staff were not receiving adequate training and support and records at the home were also not accurate and up to date.

At this inspection we checked whether the provider was now meeting the required standard in these areas. We found that some improvements had been made in all areas of care at the home.

We found that the provider had appointed a new manager and they were applying for registration with the Care Quality Commission (CQC).

People we spoke with who lived at Elmwood House told us they were happy and liked it there.

We saw changes had been made and people's consent was now being obtained in line with legal requirements.

We found that improvements had been made to the way that care was planned and delivered at the home. Some are plans we saw, however, had important information missing and were not always fully accurate or up to date.

We saw improvements had been made to the premises that helped ensure the safety and welfare of people using Elmwood House.

We found although medication was generally managed safely, people were not fully protected from risk.

Staff told us they had regular supervision and support from the manager. Training had been provided for staff but there were some gaps in records.

We found that records were generally accurate and fit for purpose at the home.

We saw an effective system of quality monitoring had been introduced that included a range of checks and audits.

At this inspection we checked whether the provider was now meeting the required standard in these areas. As the registered manager was absent from the home, the provider had appointed an interim manager for Elmwood House.

We found that although some changes had been made people's consent was still not being obtained in a way that met legal requirements. We saw that new, improved care planning documentation contained inaccuracies and omissions. We observed that people were still not receiving safe and appropriate care in practice.

Although improvements had been made the premises were not fully safe for people living there. We saw records were not fully accurate and complete and that effective systems were not in place to monitor care and identify and manage risks.

We found that sufficient numbers of staff were provided but that staff training, support and supervision was inadequate.

People we spoke with told us that they liked living at Elmwood House and that they were happy with the care they received.

We looked at one person's bedroom which had recently been decorated.

We found that although people's consent was being obtained for some aspects of people's care. However we also found that where people did not have the capacity to consent, for example due to their learning disability, the provider did not use the appropriate procedures in line with legal requirements.

We found that some areas of the home, including people's bedrooms, were comfortable and personalised. However the provider needs to continue with the improvements to ensure that the premises were safe and people are protected against unsafe and unsuitable premises.

We found that systems for monitoring the quality of the service were not fully ensuring that risks were identified and managed appropriately.

We found that peoples care files and other records were not always accurate and up to date. We found that records were now stored securely.

There were 37 people living in the home at the time of this inspection visit. We spoke with two people living at Elmwood House and they told us they were happier now. One told us they were able to have drinks in their rooms over night. Another person told they were much happier at the Elmwood House now they have moved bedrooms and were in a quieter part of the building.

We found that people at Elmwood were still not being supported safely with needs described as challenging. Proper steps had not been taken to assess and plan people's care needs and to ensure that they received the appropriate and safe care when being restrained.

We found that improvements had been made to the management of medicines. However, the provider did not have in place systems to ensure staff administered medication safely and that medicines were not stored securely.

We found that since our last inspection, Elmwood House had made improvements in the way that they recruited staff and that they now ensured that appropriate procedures were used.

We found that although people's consent was being sought for some aspects of their care that improvements needed to be made by the provider. This included that appropriate procedures were required to obtain and record consent where people were unable to make decisions for themselves, for example due to a learning disability.

We found that the provider was not making arrangements to ensure the safe management of people's medication. They were also not ensuring that the planning and delivery of their care ensured people's welfare and safety.

We found that systems for monitoring the quality of the service were not fully ensuring that risks were identified and managed and people received safe and appropriate care.

We found that people care files and other records were not always accurate and up to date and that information was not always stored securely.

We found that although some areas of the home, including some people's bedrooms, were comfortable and personalised that the provider needed to make improvements to ensure that the premises were safe and suitable for people receiving care.