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Elsenham House Nursing Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 25 April 2019

About the service: Elsenham House Nursing Home is a care home, providing personal and nursing care for up to 36 people living with complex mental health conditions and or learning disabilities. At the time of the inspection, 22 people were receiving care. Elsenham House consists of five houses, in two blocks.

People’s experience of using this service:

People who live at Elsenham House Nursing Home were not always having their needs met by sufficient numbers of suitably trained staff. The service had identified shortfalls in training, and staff were booked on training courses across 2019, however, this training was not fully completed or embedded into practice at the time of inspection. Improvements had been made to the care environment to make it cleaner and more was comfortable, however we continued to identify some concerns around the management of risks, particularly relating to fire safety.

The service was working with an external consultancy company. This company was leading with many of the internal auditing and quality checking processes. As the consultancy companies’ level of involvement reduces, the service will need to demonstrate they can recognise and act on shortfalls when identified. We identified examples of incidents that should have been notified to CQC, but had not been.

People were accessing more activities and being encouraged to go on trips and access education courses. Staff showed more kindness and compassion at this inspection. People were offered a choice of meals and the service had sourced guidance from a dietician. Improved levels of monitoring were in place for those people assessed to be at risk of poor food and fluid intake.

Management plans were in place for people needing support at the end of their life. End of life care training was scheduled for 2019. The service was working hard to improve relationships with other organisations and healthcare professionals to ensure people had joined up care.

Improvements had been made to encourage people to give feedback on the service, and areas of improvement. The management team were finding ways to implement requested changes, and demonstrating where action had been taken.

Rating at last inspection: Elsenham House Nursing Home was last inspected on the 18 and 19 July 2018. As an outcome of this inspection, the service was rated as Inadequate for all five key questions. The last inspection report was published 16 November 2018.

There was a breach of Regulation 9, 10, 11, 12, 14, 16, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Why we inspected: The service was placed in special measures, as an outcome of being given an overall rating of Inadequate. Services placed in special measures are inspected within six months of the publication date of the report to determine if sufficient levels of improvement have been made.

Enforcement At the last inspection, we identified nine breaches of regulation, and issued requirement notices. The service provided a written action plan detailing how they would address these areas of concern. The action plan was reviewed as part of this inspection, with the details of our findings explained within the body of the report.

At this inspection, we identified a repeated breach of regulation 12 and a new breach of registration regulation 18.

Follow up: We will continue to monitor this service and will reinspect in line with our schedule for those services rated as Requires Improvement. As an outcome of this inspection, the decision was made for the service to be taken out of special measures.

Inspection areas


Requires improvement

Updated 25 April 2019

The service was not always safe

Details are in our Safe findings below.


Requires improvement

Updated 25 April 2019

The service was not always effective

Details are in our Effective findings below.


Requires improvement

Updated 25 April 2019

The service was not always caring

Details are in our Caring findings below.



Updated 25 April 2019

The service was responsive

Details are in our Responsive findings below.


Requires improvement

Updated 25 April 2019

The service was not always well-led

Details are in our Well-Led findings below.