CQC report explained · a residential care home
What the CQC found at Estherene 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, December 2021
Rated Good; inspectors found that safety and management had improved, and the home had left special measures.
The inspection was unannounced and took place on 14 December 2021. One inspector spoke with people, a relative and staff, and reviewed care records, recruitment files and other safety and quality records.
Inspectors found that required fire safety and water safety work had been completed. Medicines were managed safely, staffing levels met people's needs, the home was clean, and staff were using protective equipment correctly.
Care plans and risk assessments had improved. The provider had also strengthened its quality checks by appointing a staff member to oversee audits. One care plan still needed some work, and staff needed to record care interventions more consistently.
The overall rating was Good, as were Safe and Well-led. The previous rating was Inadequate, but the provider was no longer in breach of regulations and the home was no longer in Special Measures.
Fire and water safety
Work identified in earlier fire and water safety assessments had been completed. Further work, including replacing the boiler, had also improved the heating.
“At this inspection we found that the provider had completed all the work required and had carried out additional improvement works such as replacing the boiler” from the report
Safe medicines
Medicines were managed and given safely. Stock counts matched the medicines records, and checks were carried out regularly.
“Medicines were managed and administered safely.” from the report
Staffing and recruitment
Inspectors found enough staff to meet people's needs when care was needed. Recruitment checks helped ensure staff were suitable for their roles.
“There were enough staff to support people at the time they needed it.” from the report
Infection control
The home had improved its use of protective equipment and had suitable measures to reduce the spread of COVID-19 and other infections.
“At this inspection we found that the registered manager had taken robust action with regard to this and staff were now wearing PPE correctly.” from the report
Improved quality checks
A new quality assurance role had been created. Audits were already helping identify risks and improve care planning.
“They had made a permanent appointment and this staff member had already started carrying out themed audits in the service.” from the report
One care plan still needed work
needs fixingCare planning had improved, but one care plan still had shortfalls. The provider was taking action, and inspectors did not think this had affected the person's safety.
“At this inspection we found that these improvements had been made in all but one care plan.” from the report
Care records were not always complete
minorStaff needed to record care interventions more consistently. Inspectors said this had not affected the care delivered at the time.
“Some improvements are still required to ensure staff record care interventions consistently, but this did not have an impact on the care delivered.” from the report
- 01What action has been taken to complete the remaining care plan improvement?
- 02How do managers check that staff record care interventions consistently?
- 03What results have the new quality assurance audits produced since the inspection?
- 04How are fire safety, water safety and heating checks kept up to date?
- 05How does the home collect and act on feedback from residents, relatives and staff?
This was a planned inspection following the previous rating and covered Safe and Well-led; no ratings were given for Effective, Caring or Responsive. This explanation was written from the published report of 25 December 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, April 2021
Rated Inadequate and placed in special measures; inspectors found serious safety and leadership failures despite safe medicines and enough staff.
This was an unannounced focused inspection after whistleblowers raised concerns about staffing and safety. One inspector spoke with five people and seven staff, and reviewed care records, medicines records, staff files and management records.
The home was rated Inadequate overall, with Safe and Well-led both rated Inadequate. Inspectors found long-standing fire and water safety actions had not been completed. Care plans did not always describe people's risks accurately, and some staff did not use masks and other protective equipment correctly.
There were also some positive findings. Medicines were managed safely, there were enough staff, recruitment checks were robust, and people said they felt safe. However, the provider had not acted quickly enough on known risks or on the registered manager's requests for improvements.
The home was placed in special measures. CQC said it would usually be re-inspected within six months if it did not propose cancelling the provider's registration. The report says that failing to improve could lead to action to prevent the provider from operating the home.
Safe medicines
Inspectors found that medicines were administered and managed safely, including information about people's preferences and as-needed medicines.
“Our observations and an audit of medicines assured us that medicines were managed and administered safely.” from the report
Enough staff
People and staff said there were enough staff, and inspectors observed enough staff to meet people's care needs.
“Our observations confirmed there were sufficient numbers of staff to meet people's care needs and spend time with them, engaging them in activity.” from the report
Recruitment checks
Recruitment procedures helped check that staff were suitable for their roles.
“Recruitment procedures were robust and this ensured that people recruited were of suitable character and background for the role.” from the report
People felt safe
Although inspectors found serious risks, the people they spoke with said they felt safe in the home.
“One said, "I feel very safe here and don't need to worry.” from the report
Manager's relationships
Inspectors saw that the registered manager knew people well and had positive relationships with them.
“It was clear from observations that the registered manager had positive relationships with people using the service and knew them well.” from the report
Fire safety work delayed
seriousFire safety improvements identified years earlier were still incomplete. CQC said this increased the risk of harm if there was a fire.
“The providers inaction meant that people were placed at an increased risk of coming to harm in the event of a fire at the service.” from the report
Water safety actions incomplete
seriousActions from legionella risk assessments in 2018 and 2021 had not been completed. This increased the risk of people becoming seriously ill.
“The providers inaction placed people at an increased risk of contracting Legionnaires disease and becoming unwell.” from the report
Incorrect risk information
seriousSome electronic care records contained incorrect information about modified diets for people at high risk of choking. Other care plans did not give enough guidance about preventing pressure ulcers.
“This meant it reflected that they were able to tolerate foods of a thicker consistency than was safe for them.” from the report
Infection control practice
seriousSome staff did not wear masks correctly and were not always seen using gloves or changing aprons between tasks while supporting people.
“A number of staff were observed to not be wearing their masks appropriately, this included when supporting people directly.” from the report
- 01Have all the fire safety works identified in the 2016 and 2021 assessments now been completed, and can you show us the latest fire risk assessment?
- 02Have all actions from the legionella risk assessments been completed, and how is water safety now checked?
- 03How do you make sure electronic care plans correctly record modified diets and choking risks?
- 04What checks are now in place to ensure staff wear masks and use gloves and aprons correctly?
- 05What conditions did CQC impose on the registration, and what improvements have been completed since this inspection?
This was an unannounced focused inspection of Safe and Well-led only after whistleblower concerns; Effective, Caring and Responsive were not assessed and have no new ratings in this report. This explanation was written from the published report of 6 April 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 Estherene House
5 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- December 2021Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2021InadequateSafe: InadequateWell-led: Inadequate
- December 2020Inspected but not ratedSafe: Inspected but not rated
- February 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- January 2018Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Good
- October 2015
Registered with the Care Quality Commission on 16 October 2015.
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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