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Archived: Elsinor Residential Home Inadequate

Inspection Summary

Overall summary & rating


Updated 8 September 2020

About the service

Elsinor Residential Home is a residential care home that is registered to provide accommodation and personal care for up to 35 adults and people living with dementia. At the time of the inspection there were 16 people living at the service.

People’s experience of using this service and what we found

People Living at Elsinor Residential home did not receive a safe, well led service. Infection control procedures were not followed, and people were exposed to this risk of infection due to the poor infection control practices of staff.

Care plans and risk assessments did not contain information to provide the safe care and support people required. Risk management was not in place for some people who were at high risk of developing a pressure ulcer. Where risk assessments were completed, they had not been updated in over six months, despite the person’s needs changing.

Systems were not always implemented to ensure the effective management of medicines. Staff who were administering medication were not trained and did not have their competencies checked to ensure correct procedures were followed.

Incidents were not always escalated appropriately by the registered manager or reported to the safeguarding authority. A number of safeguarding concerns, relating to pressure area care and delays in requesting professional intervention, were identified by the local authority.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The registered manager was not present at the service. The provider had a lack of oversight of people’s basic care needs and the governance of the service. Systems or processes were not established and operated effectively to ensure compliance with regulations.

A registered manager from another service within the provider group was providing support to the service. They failed to monitor and assess the quality and safety of the service or the welfare of people. Staff did not receive effective support from the management team and lacked understanding of their roles and the principles of providing high-quality care. The lack of robust management meant there was no consistent oversight of the service.

For more details, please see the full report which is on the Care Quality Commission website at

Rating at last inspection

The last rating for this service was requires improvement (published 31 October 2019) and there were two breaches of regulation. The service has been rated requires improvement for five consecutive inspections. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

We received concerns in relation to poor management of infection control, pressure area care, and weight management, poor record keeping and the overall management of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Elsinor Residential home on our website at


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and pr

Inspection areas



Updated 8 September 2020

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 1 November 2019

The service was not always effective.

Details are in our effective findings below.



Updated 1 November 2019

The service was caring.

Details are in our caring findings below.


Requires improvement

Updated 1 November 2019

The service was not always responsive.

Details are in our responsive findings below.



Updated 8 September 2020

The service was not well-led.

Details are in our well-led findings below.