CQC report explained · a residential care home
What the CQC found at Elsenham House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, November 2022
Rated Requires Improvement; inspectors found unsafe medicines management and weak oversight, although staff knew people well and supported their choices.
This was an unannounced focused inspection on 23 and 30 August 2022. Inspectors reviewed Safe, Effective and Well-led. They spoke with people, a relative and staff, and checked care records, medicines, training and management records.
The home supported 26 people at the time, mainly people with complex mental health conditions, including some people with a learning disability and/or autism. Staff understood people well, supported choices and helped people take positive risks. People said they felt safe, had enough food and could access healthcare.
There were important safety problems. Inspectors found medicines were not always given or recorded safely. Infection control, financial support, incident reporting and care records also needed improvement. The systems used by managers had not reliably found or fixed these problems.
The overall rating remains Requires Improvement. Safe, Effective and Well-led were also rated Requires Improvement. The home has held a Requires Improvement or Inadequate rating for the last four inspections.
Staff knew people well
Staff understood people's individual needs and supported them to make choices. People were supported to take positive risks in ways that promoted control and independence.
“People were supported by staff who knew them well and supported them to make choices.” from the report
Training and skills
Staff had training relevant to mental health, learning disability and physical interventions. Nursing staff had their competence checked and were supported with their professional registration.
“Staff had received a range of training in areas relevant to the needs of people they support.” from the report
Food and drink
People could choose what to eat and inspectors noted improvements in making sure people had enough food and drink.
“People told us they were happy with the food provided and were able to make choices regarding what they wanted to eat.” from the report
Access and community life
People could leave the home and receive visitors without restrictions. Staff also used local links to help people engage with the community.
“There were no restrictions on people visiting or leaving the care home.” from the report
Medicines were not safe
seriousInspectors could not confirm on five occasions that medicines had been given as prescribed. Some medicines were given together when they should not have been, records were unclear, and guidance for 'as required' medicines was missing.
“Medicines were not managed safely. This placed people at risk of harm.” from the report
Weak management checks
seriousAudits had not found or fixed several problems, including medicines, infection control, care records and checks relating to self-harm risks. The provider remained in breach of the governance regulation.
“Governance systems remained ineffective. This was a breach of regulation 17” from the report
Care information was incomplete
needs fixingCare plans and risk assessments did not always give staff enough accurate information, including about substance or alcohol misuse, health appointments and hospital admissions.
“People's records did not always contain accurate, complete and contemporaneous information.” from the report
Infection control gaps
needs fixingInspectors found gaps in entry procedures and mask access. COVID-19 risks had not been formally assessed for people and staff, and audits had not identified these issues.
“Adequate donning and doffing stations were not in place at the rear entry point of the building.” from the report
Limited support model
needs fixingThe previous recognised mental health model was no longer being used, while alternative recognised approaches had not been considered. Behaviour support plans were limited.
“Best practice in supporting people with a learning disability and/or mental health condition had not been implemented.” from the report
- 01How do you now check that every medicine is given at the correct time and recorded accurately?
- 02What action has been taken to provide clear guidance for 'as required' medicines and to prevent double doses?
- 03How are care plans and risk assessments kept accurate and complete, including information about substance or alcohol misuse?
- 04What independent checks are now made on people's money and financial support?
- 05What has changed in the infection control arrangements and formal COVID-19 risk assessments since this inspection?
This was a focused inspection of Safe, Effective and Well-led, including infection control under Safe; Caring and Responsive were not inspected and their previous ratings were carried over. This explanation was written from the published report of 10 November 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.
What inspectors found, January 2021
Rated Requires Improvement; inspectors found serious gaps in risk management, incident reporting and quality checks.
This was an unannounced focused inspection on 2 and 14 October 2020. Two inspectors spoke with people and staff, observed care, checked care, medicine and staffing records, and reviewed how the home was managed.
The home was not always keeping people safe. Records of food, fluids, weights and repositioning had gaps. Cleaning chemicals were accessible in some areas. Some incidents and safeguarding concerns had not been reported to CQC or the local authority.
The home was rated Requires Improvement overall, and also Requires Improvement for Safe and Well-led. The other areas were not inspected during this visit, so their earlier ratings were used in the overall rating.
Staff availability
The home said staffing levels were reviewed against people's needs. Most people said staff were available when support was needed.
“People told us there tended to be enough staff available to support them as required.” from the report
Medicines support
Records showed medicines were given as prescribed. Staff adjusted medicine rounds to people's needs and supported some people to manage parts of their medicines independently.
“Records showed people were being given their medicines as prescribed.” from the report
Kind medicine care
Nurses knew people's individual needs and were described as kind when giving medicines.
“Staff were knowledgeable about the individual needs of the people under their care and were kind and caring in their manner whilst giving medicines.” from the report
Food and choice
People gave positive feedback about improvements to the food and the choices available.
“People also told us they had the opportunity to try food from other countries cooked by members of staff.” from the report
Listening to feedback
People said they were listened to. The home used meetings, feedback boxes and a board showing actions taken in response.
“People told us they felt listened to, and the service was making improvements in response to their feedback.” from the report
Food and fluid records
seriousRecords had considerable gaps, so staff could not reliably tell whether some people had eaten and drunk enough. Snacks were also not always recorded.
“The quality of information recorded would not enable staff to confidently assess if people had eaten and drunk enough across a 24-hour period.” from the report
Skin care and repositioning
seriousOne person at very high risk of skin ulcers was not repositioned as often as their care plan required. The gaps placed the person at significant risk of further skin deterioration.
“This placed the person at significant risk of experiencing further deterioration in the condition of their skin and staff were not following the recommendations in place to maintain the person's safety.” from the report
Unsafe access to chemicals
seriousCleaning chemicals were found in communal bathrooms where people could access them without supervision. This conflicted with the home's own records about the risk of people ingesting chemicals.
“Items were found in communal bathrooms, which could be used without staff supervision.” from the report
Incidents not reported
seriousSome incidents and safeguarding concerns were not reported to CQC or the local authority as required. This was a repeated regulatory failure.
“We continued to identify examples of incidents which should have been notified to CQC in line with the registered manager's legal responsibility.” from the report
Weak quality checks
needs fixingAudits did not identify problems with food, fluid, weight and repositioning records, access to chemicals or some incident trends. This meant risks and shortfalls were not being tracked reliably.
“This did not provide us with assurances of the completion of thorough audits or that concerns were being tracked back and investigated.” from the report
Infection control guidance
needs fixingThe home was not fully assured in its testing arrangements, cleaning guidance and infection control policies. Some guidance was not up to date or easy for staff to access.
“We were not assured that the provider was making sure infection outbreaks could be effectively prevented or managed; as not all guidance for staff was up to date or accessible for them to follow in the absence of the registered manager being on site.” from the report
- 01How do you now check and record people's food, fluid, weight and repositioning needs?
- 02What controls are in place to keep cleaning chemicals inaccessible to residents?
- 03How are safeguarding concerns and other incidents reported to CQC and the local authority?
- 04What changes have been made to quality audits so they identify missing care records and unsafe practice?
- 05How do staff access current infection control guidance when the registered manager is not on site?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from earlier comprehensive inspections. This explanation was written from the published report of 13 January 2021 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 Elsenham House
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- November 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- January 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2019Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- November 2018Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 4 January 2011.
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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Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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