CQC report explained · a residential care home
What the CQC found at Encompass Care Specialist Mental Health Services Elsadene
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about most infection-control arrangements. They were only somewhat assured that PPE was always used safely and effectively because some staff needed reminders.
- Effective?
- Good
- This area was not assessed in this targeted inspection.
- Caring?
- Good
- This area was not assessed in this targeted inspection.
- Responsive?
- Good
- This area was not assessed in this targeted inspection.
- Well-led?
- Good
- This area was not assessed as a separate question in this targeted inspection, although inspectors noted infection-control leadership, audits and action plans.
What inspectors found, March 2021
Inspected but not rated; inspectors found strong infection-control arrangements, but some staff needed reminders about PPE.
Inspectors visited the home on 24 February 2021. This was an announced, targeted inspection during the coronavirus pandemic. It looked at infection prevention and control, rather than the home's overall quality.
Inspectors were assured about visitor safety, admissions, testing, hygiene, outbreak planning and the infection-control policy. There was an infection-control lead, regular audits and action plans.
Inspectors were only somewhat assured that PPE was always used correctly. Some staff needed reminders about when to put on and take off PPE, and refresher training was planned.
The service was inspected but not rated. This report does not give an overall quality rating or ratings for the other areas of care.
Infection-control leadership
An infection-control lead helped housekeeping and care staff work together. Audits and action plans gave the provider oversight of infection-control measures.
“There was an infection control lead. This enabled the housekeeping team and care staff to work effectively together to ensure infection prevention and control measures were followed” from the report
Testing and outbreak planning
The home carried out regular COVID testing for staff and residents. It also had plans for a COVID outbreak or another emergency.
“Regular COVID testing was carried out at the service for both staff and people living there, and contingency plans were in place in the event of any outbreak of Covid-19 or other emergency.” from the report
Support for staff
Staff could access training about their emotional response to the pandemic and counselling support.
“The provider had ensured staff had access to training about their emotional response to the pandemic and to counselling support.” from the report
PPE technique
needs fixingSome staff needed reminders about putting on and taking off PPE correctly. The provider planned refresher training for all staff.
“Although staff had received PPE training , some staff needed to be reminded when to put on and take off PPE appropriately.” from the report
- 01Has all staff refresher training on putting on and taking off PPE been completed?
- 02How do you check that staff use PPE correctly in practice?
- 03What infection-control actions were identified by the audits, and have they all been completed?
- 04How often are residents and staff tested, and what is the plan if there is a COVID-19 outbreak?
- 05How are residents supported to understand infection-control measures such as masks and aprons?
This was an announced, targeted inspection of infection prevention and control during the coronavirus pandemic; it did not assess the home's overall quality or the other care questions. This explanation was written from the published report of 10 March 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.
What inspectors found, September 2018
Elsadene was rated Good overall; inspectors found safe, kind and personalised care, with minor improvements still planned.
Inspectors visited on 30 and 31 July 2018. The first day was unannounced and the second was announced. They spoke with people living at the home, relatives, staff and health professionals. They also reviewed care records, medicines, recruitment, training, complaints, safety checks and quality audits.
The home supported 11 people at the time of the inspection and could accommodate up to 13 adults with complex mental health needs. Inspectors found enough staff, safe medicines management, clean surroundings and good safeguarding practice. People received support with their health, food, activities, independence and contact with family and friends.
Inspectors found staff to be kind and respectful. Care plans were personalised and regularly reviewed. The home had a positive management culture, listened to people's views and worked with health and social care professionals.
The overall rating was Good. Safe, Effective, Caring, Responsive and Well-led were all rated Good. The home had changed its registration from a hospital to a care home in January 2018, so this inspection used the care home assessment framework.
Kind and respectful care
Inspectors saw warm, positive interactions. Staff supported people's privacy, dignity, choices and emotional wellbeing.
“Staff consistently demonstrated a kind and caring approach towards people.” from the report
Safe staffing and medicines
The home had enough staff for people's needs and could respond flexibly when situations changed. Medicines were given on time and as prescribed.
“There were enough staff to keep people safe and meet their needs.” from the report
Personalised support
Care plans included people's needs, preferences, abilities and support networks. Reviews involved people and, where appropriate, relatives and professionals.
“Care plans were comprehensive, person-centred and included evidence of regular reviews of people's care and support needs” from the report
Activities and independence
People could choose from activities, spend time alone or join others. Staff adapted activities to people's interests and encouraged independence.
“These supported and motivated people to maintain their interests and develop new skills.” from the report
Open management
Managers were respected and approachable. Staff could raise concerns and suggest improvements, while audits and meetings informed an action plan.
“There was an open and inclusive culture where team building helped staff to feel comfortable and able to raise concerns or put forward ideas.” from the report
No dependency tool
minorThe home did not use a formal dependency tool to help calculate staffing needs. Inspectors accepted that the stable and experienced staff team was meeting people's needs at the time.
“Although the home did not use a dependency tool the stability of the staffing team and the years of experience they had helped” from the report
Relative feedback was not yet collected
minorThe home collected feedback from people living there, but did not yet routinely seek feedback from relatives or health professionals. It planned to include this in its annual survey.
“The home told us they do not currently seek feedback from relatives and health professionals but were going to do this as part of their annual survey.” from the report
- 01How do you decide how many staff and what skills are needed when people's needs change, given that the home did not use a dependency tool?
- 02How will relatives and health professionals be asked for feedback, and when will the planned annual survey take place?
- 03How would you support my relative's particular mental health needs, recovery goals and risks while keeping restrictions to a minimum?
- 04Which activities and community opportunities could be matched to my relative's interests and abilities?
- 05How would my relative and family be involved in care plan reviews and decisions about treatment or future care?
This was a full inspection of the care home under the adult social care framework, covering all five key questions; the previous inspection in February 2016 took place when the service was registered as a hospital. This explanation was written from the published report of 11 September 2018 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 Encompass Care Specialist Mental Health Services Elsadene
2 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at Encompass Care Specialist Mental Health Services Elsadene →
- September 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Encompass Care Specialist Mental Health Services Elsadene →
- June 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- March 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 15 December 2010.
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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