CQC report explained · a nursing home
What the CQC found at Elburton Heights
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risks such as falls, choking, pressure damage and moving and handling were assessed, and inspectors found medicines and infection control were managed safely.
- Effective?
- Good
- People's food, drink and healthcare needs were met. Staff had suitable training and support, and people were supported in line with the Mental Capacity Act.
- Caring?
- Good
- Inspectors saw staff treating people with kindness, respect and dignity. People and relatives said they were involved in care and supported to remain as independent as possible.
- Responsive?
- Good
- Care plans contained detailed information about people's needs and preferences. People had access to varied activities, and complaints were recorded, investigated and answered.
- Well-led?
- Good
- Inspectors found stronger quality checks and an open culture under the new registered manager. They recommended clearer recording of care tasks in the electronic system.
What inspectors found, March 2023
Rated Good; inspectors found kind, personalised care and clear improvements since the previous Requires Improvement rating, with some care-record systems still needing strengthening.
The inspection was unannounced and took place on 17 February 2023. One inspector and an expert by experience spoke with people, relatives and staff, observed care, and reviewed care, medicines, recruitment and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were treated kindly, received their medicines, had their nutritional needs met and were offered activities suited to their interests.
The home had improved since the previous inspection, which was rated Requires Improvement in November 2019. The provider had acted on recommendations about food and drink, meaningful activities and care records.
Inspectors recommended strengthening how staff record care tasks in the electronic system, because some information was recorded in different places and was not always easy to find.
Personalised care
Care plans gave staff clear information about people's individual needs, preferences and health conditions. Staff were able to explain how they supported people.
“People's care plans reflected individual needs with clear guidance for staff to follow to ensure people received person centred care.” from the report
Kind and respectful staff
Inspectors saw staff speaking respectfully, reassuring people and checking that they were comfortable. People and relatives were positive about the care.
“Throughout our visit we saw people were treated in a caring and kind way.” from the report
Food and activities
People's nutritional and fluid needs were monitored, with special diets and alternatives provided. People could choose from a wide range of activities and opt in or out.
“There was a wide range of activities offered, and throughout the day we observed people engaged with staff and enjoying what they wanted to do, alongside planned activities.” from the report
Improvement since 2019
The provider had acted on all three recommendations from the previous inspection. Ratings for Safe, Effective, Responsive and Well-led improved from Requires Improvement to Good.
“At this inspection we found the provider had acted on these 3 recommendations and had made improvements.” from the report
Care tasks recorded in different places
needs fixingSome care tasks were recorded in different parts of the electronic system. Inspectors said this meant some information was not readily accessible and recommended stronger recording practices.
“However, we identified areas were the systems could be strengthened in relation to the recording of care tasks.” from the report
Mixed views about staffing
minorPeople, relatives and staff gave varied views about staffing levels. Inspectors observed enough staff to meet people's needs, but families should ask how staffing is managed at different times.
“We spoke with people, staff and relatives who gave a varied response about staffing levels.” from the report
- 01How do you make sure care tasks recorded in different parts of the electronic system are not missed?
- 02How many staff are usually on duty in each unit during the day, evening and night?
- 03How do you check that people's food, drink and prescribed nutritional supplements are being recorded and provided?
- 04How are activities adapted for people living with dementia and for people who do not want to join group activities?
- 05How will you show that the new management team's improvements are continuing?
This was an unannounced inspection covering all five key questions, including infection prevention and control; inspectors reviewed care and medicines records, staffing, observations and management systems. This explanation was written from the published report of 17 March 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2022
Elburton Heights: Inspected but not rated; inspectors found strong infection prevention and control arrangements.
This was an announced, targeted inspection on 24 February 2022. Inspectors looked at infection prevention and control, visiting arrangements and whether COVID-19-related staffing pressures were affecting the service.
Inspectors found the home was clean and that regular cleaning, infection control checks and extra cleaning of frequently touched surfaces were in place. They were assured that admissions, visiting, testing, PPE, social distancing and outbreak management were being handled safely.
The report does not give an overall quality rating. The Safe question was inspected but not rated, so this report is not a full assessment of all areas of care.
Clean environment
The home had regular cleaning schedules and extra cleaning for frequently touched surfaces. Infection control audits were carried out and actions were followed up when needed.
“The service was clean and fresh, staff carried out a regular cleaning schedule.” from the report
Safe admissions
New admissions required a confirmed negative COVID-19 test. The environment had been assessed so people could be allocated safely if they needed to isolate.
“The provider had robust systems to ensure safe admissions, including only allowing new admissions after a confirmed negative result of the Covid-19 test.” from the report
PPE and infection training
Staff had training on infection control and PPE. Their competence was checked regularly, and there was a designated area for putting on and removing PPE.
“Staff's competency around infection control and PPE was checked regularly to prevent staff complacency.” from the report
Outbreak planning
The management team had a contingency plan and risk assessments for COVID-19 outbreaks. Provider audits supported quality and assurance checks.
“There was a comprehensive contingency plan of what to do in case of an outbreak.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you currently managing any staffing pressures, and what effect have they had on residents?
- 02How often are infection control and PPE competencies checked now?
- 03What are the current visiting, testing and PPE arrangements for relatives and other professionals?
- 04How would the home manage an infection outbreak, and when was the contingency plan last reviewed?
- 05How are new admissions assessed and supported if they need to isolate?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it did not provide ratings for the other key questions. This explanation was written from the published report of 13 April 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Elburton Heights
5 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- March 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2022Inspected but not ratedSafe: Inspected but not rated
- November 2019Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2019Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- September 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2017Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2016
Registered with the Care Quality Commission on 3 June 2016.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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