Elsenham House

On this page

• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

Caring – this means we looked for evidence that the provider involved people and treated them with compassion, kindness, dignity and respect.

At our last assessment we rated this key question requires improvement. At this assessment the rating remains the same. This meant people did not always feel well-supported, cared for or treated with dignity and respect.

This service scored 45 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always treat people with kindness, empathy and compassion and respected their privacy and dignity. Staff treated colleagues from other organisations with kindness and respect. We observed staff were polite and spoke openly with other staff and people using the service. We found however that the environment did not uphold people’s privacy and dignity. Shared rooms did not enable people to have private space, and shared facilities did not enhance people’s privacy. We noted a staff member having a private conversation in public. Flooring in the home had a strong malodour which is not in keeping with upholding people’s dignity. Safeguarding concerns had been raised in regard to some peoples living conditions, but it was clear people had lived this way for some time.

The provider did not always treat people as individuals and make sure people’s care, support and treatment met people’s needs and preferences. They did not always take account of people’s strengths, abilities, aspirations, culture and unique backgrounds and protected characteristics.

People were not supported through reviews to forward plan and think about what they would like to achieve. Although care plans were robust documents, they were not routinely shared by people who used the service. Surveys and meetings did not clearly show how peoples feedback was used to influence service improvements and people had lived in poor conditions for a number of years.

Relationships with families in some cases were fragmented and it was difficult to see how the staff regularly engaged with family. One relative told us they were only told when something happened such as an incident rather than receiving regular updates on their family members well-being, activity etc. There were no relatives’ meetings or newsletters.

We noted a person with cognitive decline and support to access bespoke activities to enhance their wellbeing had not been developed and the person had not been supported to maintain their skills. Their preference was to stay in their room, and we noted that this was the case for other people but the reasons for this had not been fully explored.

Activities had been overhauled with a staff member taking responsibility for planning and developing leisure opportunities. These however mostly benefited those with agreed 1-1 support and were limited in their nature. Group activities did not enable staff to explore people’s individual interests with them or ensure activities were age appropriate.

There were very few evening activities or opportunities for these due to the reduction in staffing levels after 6 pm.

The provider did not always ‘people’s independence, so people knew their rights and had choice and control over their own care, treatment and wellbeing.

People’s care plans stated what support people needed but it was less clear actions staff should take if people refused any aspect of their care or the impact that could have. People were encouraged to keep their environment tidy but if they chose not to there were no consequences. The service due to staffing tended to do things around staffing availability rather than people’s choice so this impacted on people’s experiences. For example, shopping was on a set day and shopping was completed for all houses rather than having individual shopping days.

Restrictive practices had not been identified by staff or acted upon which reduced people’s autonomy and control. For example, food cupboards being locked as well as fridges. Access to a cool drink for example relied on support by staff.

The provider mostly listened to and understood people’s needs, views and wishes. Staff mostly responded to people’s needs in the moment and acted to minimise any discomfort, concern, or distress. Processes were in place to ensure staff were adequately trained and supported in the workplace to meet the needs of people using the service and with the input of other health care professionals. Improvements in the service delivery so they were more in line with people’s individual needs, had recently been introduced but this seemed to be as a direct result of a specific incident and change of management. This meant staff had not always identified or responded to people’s individual needs or protected them from avoidable harm.

People were consulted but we found there were no recorded complaints or concerns particularly as people vocalised concerns to us about their day-to-day needs. The provider had noted in the provider information return for February 2025 that complaints had been received from neighbours. As this was not recorded in the complaints log, we cannot see how the provider responded.

Resident meetings and surveys were held but these did not provide clear evidence of what and how information was collated and used to inform service user improvements. Staff were supported with the knowledge needed to support people but there was a lack of investment in staff to ensure they could progress professionally if they wished to.

The provider did not demonstrate how it cared about and promoted the wellbeing of their staff and supported and enabled staff to always deliver person-centred care. Whilst staff views were considered we were concerned about the lack of consideration of staffs’ safety and risks associated with providing care and support. Lessons learnt were poorly developed and we expected to see evidence of clear debriefings taking place after each serious incident. Whilst staff were reporting incidents we saw where staff had been assaulted and the impact of this had not been considered.