Elstow Manor

Updated 1 December 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by two inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Elstow Manor is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Elstow Manor is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post. The registered manager was due to move on to another role within the company and so was in the process of handing over to another manager. The new manager will be applying to the CQC to become the registered manager.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since it was registered with the CQC. We sought feedback from the local authority, Healthwatch England and professionals who work with the service. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke to eight people and 16 of their relatives about their experiences of living at Elstow Manor. We spoke with four professionals who worked regularly with the service and 16 members of staff. This included the registered manager, the new manager and the clinical lead. We also spoke with staff from various departments such as catering, housekeeping, maintenance, wellbeing and lifestyle coach, nursing, support staff and agency staff.

We reviewed seven people’s care records and 12 people’s medicine records. We looked at two staff files to review recruitment processes and documentation. We looked at various policies and other health and safety and quality assurance records.

Updated 1 December 2022

About the service

Elstow Manor is a residential nursing home providing personal and nursing care to up to 80 people. The service provides support to people living with dementia as well as some physical health conditions. At the time of our inspection there were 38 people using the service.

People were supported in a purpose built building across three floors. The top floor was currently unused. There were lounges, dining areas and other communal spaces on each floor. One floor had a cinema and on other floors there was a hairdressing salon and bistro. There was a garden area which included a small play area for visiting children. There was an office onsite and the layout was designed in a way to support people with mobility needs to freely access any area.

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

People were supported to safely administer their medicines and agreed with staff and medical professionals what time they would like to take them. However, the registered manager was taking action to improve the administration records and systems for managing excess stock of medicines.

People were supported by trained staff in all aspects of their daily life. This included going out of the home, maintaining contact with friends and relatives, having meals and drinks, socialising and meeting their health needs. However, people felt that staffing shortages had an impact on some people’s experiences of their care. The registered manager was in the process of a recruitment drive to help with the continuity of care.

People were able to speak with the registered manager when they had concerns and told us they acted very quickly to resolve them. The registered manager monitored all aspects of people’s care but medicines audits were not always effective at identifying areas for improvement. The registered manager was aware of this and taking action to improve systems and processes.

People told us they felt safe living at Elstow Manor. They liked the staff and told us staff treated them well, were kind and met their needs. Staff knew how to keep people safe and what to do if they had any concerns. People told us living at Elstow Manor was like living in a five star hotel.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The registered manager made sure all staff and visitors followed the latest government guidance for reducing risks about COVID-19 and the spread of infection. Staff had received additional training on this topic to ensure they could keep people as safe as possible.

People had access to health professionals who worked closely with the staff and management team to ensure all health concerns were looked into straight away. The nursing staff were able to observe and record basic health observations such as blood pressure and oxygen levels to help professionals get the right information and monitor people’s well-being quicker.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 16 July 2021 and this is the first inspection.

Why we inspected

This inspection was planned based on the date the service was registered with the CQC. We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.