Elm House 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

People were not kept safe and were at risk of avoidable harm. We found breaches of the legal regulation (safe care and treatment). People's medicines were not managed safely. There were ineffective systems and processes resulting in medicines errors which could have caused potential harm to people. There was no system to manage and oversee incidents and accidents, and safeguarding concerns to make sure lessons were learned to improve practice. There were gaps in people's risk assessments and care plans and at times guidance for staff was incorrect. We were unable to see a robust process around pre-admission assessments for people to make sure the service could meet the needs of people before they moved to the care home. However, the environment was safe, clean and comfortable. Staff were recruited using safe recruitment processes, and there were enough staff to meet people's needs. Training for staff was up to date.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff documented information on paper templates following an incident. However, the templates did not include enough information to make sure incidents could be analysed and mitigated against happening again. The management team told us the service planned to move to electronic incident forms, which did contain relevant information, however this was not yet embedded.

We did not see what the process was for dealing with incidents, and analysing them to make sure mistakes were not repeated. This meant there were lost opportunities to learn lessons and improve practice. This was a concern following the previous inspection in October 2023 and was a continued breach of the legal regulation (safe care and treatment).

Partners felt that systems, pathways and transitions could be improved to allow for better outcomes for people.

At times systems were not in place to ensure good transition of care. For example, there was no proper process for conducting pre-admission assessments prior to people moving into the home, or for people being re-admitted following a stay in hospital. Staff made referrals to other agencies where appropriate, for example the local mental health team.

People said they felt safe and well cared for. However, we were aware that at times people had not been appropriately safeguarded due to ineffective processes and admission procedures.

Staff understood what constituted a safeguarding issue and knew what to do if they had any concerns. Staff completed safeguarding training and this was up to date.

There was no system for managing safeguarding concerns. Although there was a relevant safeguarding policy, we could not see any safeguarding records or documents, and we were unable to see what the process was to learn lessons and make improvements. This was noted at the previous inspection in October 2023 and was a continued breach of the legal regulation (safe care and treatment).

People told us they were involved in planning their care and were always asked about their health and wellbeing. Relatives agreed and said they were kept involved and always informed about changes or concerns.

Staff had good understanding about any risks and took appropriate action. Staff completed relevant training in health and safety, and moving and handling equipment. They had the right knowledge to meet people's needs. However, it was difficult to see what processes were in place to make sure risks were properly assessed and mitigated.

People told us the building and equipment was in good working order, and people had the right equipment available to meet their needs.

Staff confirmed there were appropriate processes to make sure broken items were fixed or replaced in a timely manner.

The building and environment was in a good state of repair. Equipment for moving and handling and lifts were in good working order and serviced regularly.

There were processes to make sure health and safety checks were undertaken regularly, and the maintenance system was robust.

People told us there were enough staff to meet their needs. People and relatives thought that staff had the right knowledge, skills and experience to do their jobs.

Staff said there were enough staff to cover shifts and use of agency was limited to cover staff sickness and holidays. Staff felt there had been an improvement to the amount of training they could complete and that they had the right training to do their jobs.

Staff recruitment processes had improved following the previous inspection although some historic checks still needed to be made. New staff had the necessary safety checks. Systems were needed to strengthen staff skills and competency in relation to medicines management.

The home was clean and tidy and free of hazards. We observed that people's bedrooms had been cleaned and tidied in the first part of the morning and people commented that their rooms and the building was kept clean. Staff wore appropriate PPE and washed their hands regularly.

There were effective processes to make sure the home was clean and tidy, and supported infection prevention and control.

People missed numerous medicines due to medicines not being in stock. One person did not have their high-risk medicine given at the right dose on several occasions in the previous few weeks. Two other people were not given their prescribed inhalers correctly and antibiotics were not given and recorded as prescribed. People’s health and wellbeing were at risk due to unsafe medicines management. Guidance to support staff on the application of topical medicines (creams) was not always in place and records were not accurately made when creams were applied. Care plans to support staff to safely administer when required and variable dose medicines was not always accurate and sometimes not available.

Staff told us the latest supply of monthly medicines had not arrived on time so numerous people did not receive their prescribed medicines placing their health and wellbeing at risk. Staff told us medicines audits were regularly carried out, but these were very basic and did not cover all key aspects of medicines handling. We found numerous shortfalls in medicines management that audits had failed to identify. Post inspection the service had begun to implement changes to processes following our findings. Staff told us they completed medicines training and senior staff checked their competency. However, we found a number of instances when staff had not followed safe and best practice when administering and recording medicines.

Processes to manage medicines were not safe and placed people at the risk of harm. This was a breach of the legal regulation (safe care and treatment). Ordering systems were not effective, and stocks were not safely managed and recorded. The latest monthly order had not been delivered on time resulting in some people missing their prescribed medicines. Excessive amounts of medicines were discarded at the end of each month because ordering systems were not effective or efficient. Medicines records were not accurately completed. Thorough checks had not been made at the beginning of the previous month so medicines records did not match people's prescriptions. Handwritten records did not follow national standards and guidance including accurate recording of dates, and recording people’s medicines allergies. Medicines were not always stored securely and safely. Temperature monitoring of the medicines fridge and room were not consistently recorded. Medicines awaiting disposal were not stored safely or according to national guidance. Medicines trollies were available for some medicines, but these were not large enough to hold and transport all medicines.