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Elsenham House Nursing Home Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 13 January 2021

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 and autism. 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 and what we found

People were not always being protected from risk of harm, particularly in relation to the protection of their skin, nutritional intake and access to certain risk items within the care environment. We identified examples of incidents that had not been reported to the local authority safeguarding team or to CQC to ensure people’s safety was being maintained.

People gave positive feedback about the care they received, the support provided by staff and told us that the quality and choice of the food had improved. However, one person did tell us that they did not always feel safe living at the service.

We sourced assurances from the registered manager that there were sufficient numbers of staff on shift during the day and overnight to meet people’s individual risks and needs. Most people told us they were able to access staff support when needed. One person told us there were less staff available during meal times.

Rating at last inspection (and update)

Elsenham House Nursing Home was last inspected on the 21 February 2019, the report was published 25 April 2019. As an outcome of this inspection, the service was rated as Requires Improvement. With breaches of Regulation 12, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 18 of CQC Registration Regulations (2009).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

Why we inspected

We received concerns in relation to the management of risks relating to people and the care environment during the Covid-19 pandemic period. We met with the provider and local authority quality assurance team during the pandemic period to seek assurances from the provider that the required level of improvement would be made. The decision was made to undertake a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. 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 remained Requires Improvement. This is based on the findings at this inspection.

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 coronavirus and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvement. Please see the Safe and Well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Elsenham House Nursing Home on our website at www.cqc.org.uk.

Enforcement

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 proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment, good governance and notifying CQC of incidents at this inspection. Full information about CQC’s regulatory response to the more serious conc

Inspection areas

Safe

Requires improvement

Updated 13 January 2021

The service was not always safe.

Details are in our safe findings below.

Effective

Requires improvement

Updated 13 January 2021

Caring

Requires improvement

Updated 13 January 2021

Responsive

Good

Updated 13 January 2021

Well-led

Requires improvement

Updated 13 January 2021

The service was not always well-led.

Details are in our safe findings below.