Elmsdene 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.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

We identified a breach of the legal regulations in relation to safe care and treatment, specifically medicines management. Breaches in risk, safeguarding and staffing at the previous assessment had been met.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff recognised and documented incidents and accidents. However, we noted some gaps around the analysis of incidents and learning lessons from these.

Staff completed incident forms, and these were uploaded to the electronic care plan. Staff completed body maps following a fall although we saw 1 instance where this had been missed. We could not see any incident analysis for the service to help staff understand where improvements could be made. Following our feedback, we were made aware of changes to the management structure which resulted in direct involvement from a senior leader, and we were shown clear governance processes that the provider had established.

Staff worked with people and healthcare partners to establish and maintain safe systems of care, although some improvements were required.

The manager and staff made referrals to external agencies and shared information effectively. However, we were not assured that there was an effective admissions process to make sure that staff had all the right information about a person when they first moved into the home.

There were processes and policies to make sure that people were protected from the risk of abuse. However, the system to monitor outcomes of safeguarding investigations to make sure recommendations were implemented needed to be embedded.

Staff completed safeguarding training and knew how to report concerns. People told us they felt safe living at Elmsdene Care Home. There was appropriate information available for staff to access. The manager raised safeguarding concerns to the local authority and worked well with safeguarding professionals.

The manager agreed to strengthen their systems to ensure any recommendations following investigations were undertaken and monitored.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff assessed people’s needs and risks and reviewed them regularly. Risk assessments and care plans were updated on an ongoing basis and staff could access these easily via electronic handheld devices.

Staff completed observations and analysis when people were upset or anxious to try and find the cause and make changes if required.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety checks had been made and the service was compliant, for example regarding fire safety, gas safety and electrical equipment testing. There was an effective system to manage maintenance of the building and grounds, items were replaced or fixed quickly.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were enough staff to meet people's needs with low reliance on agency staff. There were no vacancies at the time of the assessment. The service followed safe recruitment processes and made sure safety checks such as references and disclosure and barring service (DBS) checks were made. The manager checked right to work documents where required.

Staff completed training including medicines training and staff were up to date with the completion of their courses. The service was no longer in breach of the legal regulation.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There were dedicated cleaning and domestic staff, and regular cleaning schedules and checklists were in place. We observed the home to be clean and tidy, and free of hazards. Staff cleaned people’s rooms every morning and when required.

We observed staff wearing appropriate PPE.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Staff administered medicines and documented the doses given. However, instructions such as ‘before food’ were not always followed. We found a medicines error on 1 of the records we checked, this was raised with the manager to be addressed.

Guidance about ‘as and when required’ medicines was missing for some people. Staff preparing drinks knew how to use prescribed thickeners and there was guidance displayed in the staff area. However, staff did not document when and to what level they thickened drinks. This is important as incorrect administration could cause potential harm.

Staff did not record where they applied medicine patches (rotating the site of application can reduce the risk of skin irritation). Staff could not easily access information about prescribed creams to make sure they followed correct guidance. Where medicines were crushed to aid medicines administration, guidance for staff was not sufficient, and the rationale for crushing was not clear.

The senior staff undertook medicines audits; however, these had not identified the issues we found.