Elmswood Park, an extra care service supporting 21 people, was rated Good overall and across all five key questions at this first inspection. Improvements were needed around timeliness of calls, mental capacity assessments, person-centred care planning and the effectiveness of governance audits.
Concerns (7)
moderate
Missed or late visits
: “The carers are late two to three times a week. A bit late can be half an hour late.”
moderateMissed or late visits: “On occasions we found this showed instances of short calls and gaps where staff had failed to record the call visit.”
moderateConsent / capacity: “Where restrictions were in place for one person, appropriate assessments had not been completed.”
moderateGovernance: “the providers quality assurance systems had not always been carried out effectively to identify areas for improvement.”
minorCare planning: “records relating to people's long-term conditions needed to be further developed to ensure they contained all of the information needed.”
minorPerson-centred care: “We recommend the provider consider current guidance on person centred care planning to ensure people's holistic needs are captured.”
minorStaff training: “I think the staff need more formal induction training”
Strengths
· Safe recruitment procedures in place to protect people from unsuitable staff
· Medicines managed safely with regular competency assessments
· Appropriate infection prevention and control measures, including PPE use
· Risks to people's safety and wellbeing well managed with up-to-date risk assessments
· Staff trained in safeguarding and aware of how to report concerns
Quality-Statement breakdown (21)
safe: Staffing and recruitmentNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Supporting people to eat and drink enough and access healthcare servicesNot rated
caring: Ensuring people are well treated and supported; equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Supporting people to develop and maintain relationships and follow interestsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about roles; understanding quality performance, risks and regulatory requirements; duty of candourNot rated
well-led: Promoting a positive, person-centred, open and inclusive culture; engaging and involving people and staffNot rated
well-led: Working in partnership with othersNot rated