CQC report explained · a residential care home
What the CQC found at Enstone House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always managed safely, and risks were not always assessed or acted on. Inspectors also found problems with window restrictors, an electric heater and cleaning arrangements.
- Effective?
- Good
- People's needs were assessed and reviewed, staff had induction and training, and people were supported with food, drink and healthcare. Some mental capacity assessments and consent records were incomplete.
- Caring?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Requires improvement
- The provider's audits and oversight did not reliably identify or correct problems. Records were sometimes unclear or conflicting, and action plans lacked clear timescales.
What inspectors found, July 2023
Rated Requires Improvement; inspectors found good care planning, training and dining, but serious gaps in medicines, risk checks and oversight.
This was an unannounced focused inspection. Inspectors visited on 11 and 19 May 2023, then returned on 12 June after extending the inspection to include safety. They spoke with people, relatives, staff and healthcare professionals, and checked care plans, medicines records, staff files and audits.
The home was not always safe. Inspectors found gaps in medicines records, unexplained medicine stock differences, unsafe or unassessed risks, broken window restrictors and incomplete cleaning records. There were also malodours on the first day. The home's audits had identified some problems but had not led to effective action.
The home was rated Good for Effective. Inspectors found suitable assessments, staff training and support, positive dining and timely healthcare referrals. Safe and Well-led were rated Requires Improvement. The overall rating remained Requires Improvement, and the home has held this rating for three consecutive inspections.
Staffing and training
Staff had induction, training, supervision and appraisals. Inspectors found enough staff on duty and heard that staffing levels and staff turnover had improved.
“New staff completed an induction and did not work unsupervised until they and their line manager was confident, they could do so.” from the report
Food and drink
People were supported to eat and drink in a dignified way. Inspectors saw a positive dining experience and found that staff knew people's preferences.
“People were supported with nutrition and hydration in a dignified way.” from the report
Care planning
Assessments were comprehensive and care and support were reviewed. People and relatives were involved in assessment and care planning.
“People's expected outcomes were identified, and care and support regularly reviewed and updated.” from the report
Team relationships
People, relatives and staff gave positive feedback about the management team. The home worked with healthcare professionals and other services.
“There was a clear management and staffing structure, and staff were aware of their roles and responsibilities and had confidence in the management team.” from the report
Medicine safety
seriousMAR charts had gaps, medicine stock did not always match the records, and some medicines were transcribed incorrectly. Inspectors could not be sure people had received medicines as prescribed.
“Systems had not been established to ensure proper and safe management of medicines.” from the report
Unmanaged risks
seriousInspectors found broken or unsafe window restrictors and an electric heater that had not been risk assessed. Some risk assessments and care plans also contained conflicting information.
“Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service” from the report
Cleaning arrangements
seriousThere were malodours on the first inspection day, gaps in cleaning records and no clear cleaning schedule. The home was deep cleaned later, but record gaps remained.
“On our first day of the inspection, the home had malodours.” from the report
Weak oversight
seriousAudits did not consistently identify problems or lead to completed action. Some daily records lacked detail, and the provider did not show clear proactive oversight of the home.
“The provider's quality assurance systems were not always effective and not used to drive improvement.” from the report
- 01What has been done to prevent gaps in medicine administration records and to investigate medicine stock differences?
- 02Have all window restrictors, heaters and other safety risks now been checked, repaired or risk assessed?
- 03What cleaning schedule and backup arrangements are now in place when staff or equipment are unavailable?
- 04What action plan, deadlines and checks are being used to improve care records and quality audits?
- 05How are mental capacity assessments and consent forms for information sharing, photographs and vaccinations now being completed?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 12 July 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, June 2021
Rated Requires Improvement; inspectors found safe, kind and responsive care, but records, dementia training and quality checks still needed work.
Inspectors made an unannounced visit on 11 May 2021. They observed care, spoke with people, a relative, staff and outside professionals, and checked care, medicines, staff and management records.
The home was rated Good for Safe, Caring and Responsive. People were described as safe, treated with dignity and supported with their individual needs, food, medicines, health care and activities.
Effective and Well-led were rated Requires Improvement. Capacity assessments were not always completed for specific decisions, some staff needed more dementia training, and the new quality checks had not yet been fully tested.
The overall rating stayed at Requires Improvement. This was better than the previous inspection because the home was no longer in breach of regulations, although further improvement was still needed.
Safety and medicines
People were safe, risks were reviewed when needs changed, and medicines were stored, given and recorded safely.
“People were supported to have their medicines safely and as prescribed.” from the report
Kind and dignified care
Inspectors saw gentle, unrushed care and a warm atmosphere. Staff helped people maintain their dignity and respected privacy.
“Throughout the day we observed a positive and a warm atmosphere.” from the report
Personalised support
Care plans had been rewritten to reflect individual needs and wishes. Staff responded to how people preferred to eat, communicate and spend their time.
“People's care plans had all been rewritten with consideration given to their individual needs and wishes.” from the report
Improved teamwork
The addition of a deputy manager gave the registered manager more support. Staff said communication, listening and teamwork had improved.
“This meant a number of managerial tasks were now shared by two senior staff which was a huge help to the registered manager who historically had no such support.” from the report
Capacity assessment records
needs fixingSome records covered several decisions, including decisions made weeks earlier or expected in the future. This did not follow good practice for assessing capacity.
“We however identified the records surrounding assessments of people's capacity were not always in line with good practice.” from the report
Dementia training
needs fixingThe management team planned further specialist dementia training. Inspectors also observed that some staff would benefit from it.
“Our observation confirmed some staff would benefit from such training to ensure they had the knowledge and skills to appropriately support people living with dementia” from the report
Quality checks still developing
needs fixingThe new audits had only been used for a few months and needed to be embedded. One audit did not identify the problem with capacity assessment records.
“The management team told us they had started using the new quality assurance systems in the last few months and therefore these needed embedding.” from the report
- 01How do you now make sure every capacity assessment relates to one specific decision at the time it is needed?
- 02What dementia training have staff completed since this inspection, and what further training is planned?
- 03How do you check that your care plan audits identify problems in capacity assessment records?
- 04How have the new quality assurance systems been tested since the inspection?
- 05How will you maintain personalised activities and contact with relatives if restrictions or people's needs change?
This was a planned inspection covering all five CQC questions, with observations, discussions, record checks and feedback from outside professionals. This explanation was written from the published report of 11 June 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 Enstone House
6 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- July 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2021Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementWell-led: Requires improvement
- April 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2019Requires improvementdown from GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 11 February 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
38 live-in carers within about an hour of Oxfordshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,300 a week. 32 can care for a couple. 12 years' experience on average.
“We can all fully relax around Nyarai and she feels like part of our family, which is no mean feat!”
“She was v competent and confident and we felt our mum was safe in her care. She supported us through a difficult time.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.