During an assessment under our new approach
We carried out a comprehensive assessment of Estervin Court Residential Care Home between 20 October 2025 and 29 October 2025. This assessment was prompted as the service had not been previously inspected.
During our assessment we observed care and reviewed people’s risk assessments, care plans and medicines administration records. We reviewed policies, procedures, training records, incident records and other relevant documentation.
The provider was in breach of 5 legal regulations related to need for consent, safe care and treatment good governance, staffing, and fit and proper persons employed at the service.
The provider’s governance processes were not robust, with audits and monitoring not identifying issues we noted during the assessment. There was a lack of effective oversight and monitoring of the service. Quality assurance systems and processes were not effectively implemented to ensure safety and drive improvement.
The provider did not always ensure all potential risks to people were understood and managed. People’s health was not always robustly monitored and people’s care plans lacked guidance in relation to the potential risks associated with their diagnosed specific medical conditions.
The provider did not have robust processes to identify potential health and safety issues. The provider had not ensured all risks to people had been mitigated and managed, for example, water safety, fire safety and window restrictors. Whilst there were audits completed, these did not identify all the issues we found.
The provider failed to ensure that medicines were consistently managed and stored safely.
Where people lacked mental capacity to consent to their care and treatment, best interest decisions had not been completed in accordance with the Mental Capacity Act 2005.
Staff were positive about working at the service, and they felt able to raise concerns to the management team. Recruitment processes did not ensure safe recruitment of staff.
Staff were kind, caring, and respectful towards the people in their care. Staff worked well with health providers for the best outcomes.
The management team were actively involved in the day-to-day running of the service.
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