What the CQC found at Elstow Manor

People told inspectors they felt safe. Staff knew how to recognise and report abuse and how to manage risks.

“I feel very safe, the staff are always around. The staff check on us at night and make sure we are okay.” from the report

People and relatives described staff as kind and respectful. Staff supported people's dignity, choices, independence and personal beliefs.

“People's diverse needs were respected. For example, one person who held a great importance to relationships and conversations with people who were not there in person, was supported” from the report

Care plans included people's histories, preferences, communication needs and guidance for staff. People were involved in decisions about their care and activities.

“People's care was planned individually and they told us they were given choices about what to do.” from the report

People could have visitors without restrictions on times or numbers, with infection control measures in place.

“People were supported to have visitors when they wished to do so without restriction.” from the report

There were staff vacancies and regular use of agency staff. People, relatives and staff said this affected continuity, time available and how well staff knew people's preferences.

“However, the number of agency staff currently used each day had impacted people's experience and was an area for continual review and improvement.” from the report

There were discrepancies in medicines stock and excess-stock administration records. The two most recent audits had not found these issues, making it difficult to be certain that no errors had occurred.

“However, we found the management of medicines stock and administration records for excess stock had discrepancies that had not been identified on the two most recent audits.” from the report

Some people's diet sheets were not available in the kitchen during the inspection. The manager said this was addressed afterwards.

“However, not all people's diet sheets were available in the kitchen for catering staff at the time of the inspection.” from the report

Inspectors saw differences in the service provided by temporary staff. One example involved staff not always waiting for consent before entering people's bedrooms.

“Another example included the differences in quality of service from temporary staff such as tea served with a saucer and biscuits for one person but not another and not always waiting for consent when entering people's bedrooms.” from the report