Elsenham House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Requires Improvement. At this assessment the rating has remained the same. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment, staffing and the premises and equipment.


 

This service scored 44 (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 have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The assessment to the service was undertaken due to a significant incident which the service notified us of and carried out an internal investigation which showed significant shortfalls in care. We reviewed this and other notifications, incidents and safeguarding concerns. Whilst incidents were escalated, we found it difficult to cross reference and check if all notifications had been reported to the local authority safeguarding team and CQC. We also found poor analysis of incidents, accidents, safeguarding concerns and near misses which would help to identify any themes and, or trends across the service. The manager said notifications were discussed with the provider, but we saw no evidence of this, and monthly provider audits did not tell us how risks were being identified and acted upon.

Prior to the significant incident, communication was not effective and risks to people were not clearly identified and acted upon. There was not a clear escalation process which meant people were potentially exposed to potential or actual avoidable harm. Incident records did not clearly state actions taken to support staff in managing situations safely

The provider worked with healthcare partners to establish and promote safe systems of care, in which safety was managed or monitored. Continuity of care, including when people moved between different services was promoted but we identified shortfalls. The robustness of care planning and risk assessments concerned us as we found staff were not quickly identifying and escalating people’s unmet or changing needs.

Daily notes did not give a good overview of people's needs or pick up on changes to their mental health or physical presentation. This would impact on joint working with other agencies and knowing when to involve other services to ensure there was an integrated approach to people's needs. The manager had introduced a ‘resident of the day’ so there was monthly oversight of people's needs, but again we found this process was not robust or firmly embedded. People receiving the care and support were not given access to their care plan and were not put front and centre of their care needs.

We also found that local authority statutory reviews were not up to date for most people, so local authorities were not identifying if the service remained appropriate for people’s needs and if any additional 1-1 staffing hours were being used effectively. There was an electronic care planning system but there was evidence that key documents including admission assessments were not being scanned in which meant documents were not all within the same record and therefore more difficult to locate and access.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff did not always concentrate on improving people’s lives and protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns appropriately.

Whilst we acknowledged improvements being made under the recent new management we had concerns that people had not been protected from avoidable harm and incidents did not result in robust actions always being taken.

Poor record keeping made it difficult for us to judge the effectiveness of the service in meeting people’s needs. Relatives whilst informed of incidents said aggression towards service users and, or staff did take place.

The safeguarding log did not assure us all incidents were reported. The daily notes did not assure us all incidents were reported and acted upon. Staff spoken with did show a good understanding of safeguarding and what and when to report incidents.

The provider did not work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people’s safety were identified prior to and during our assessment. The previous regulatory history of this service was poor and did not assure us of people’s ongoing safety. During our recent assessment we had concerns about staffing levels and whether people’s support needs particularly 1-1 support was being provided. Night-time staffing was particularly low, and we were not assured that 2-night staff could respond adequately to any emergency for up to 26 people. This is a concern we had raised previously during an inspection.

Some people had behaviours which could place them or others at risk. The staffing levels did not take this into account, and we were concerned that the environmental risk assessment did not consider all potential hazards to people’s safety. Restrictive practices had been adopted rather than considering the needs of each individual such as locks on the fridges.

People’s daily notes did not give us a clear overview of risk. They did not tell us how people’s behaviour had been to help ensure their mental and physical health could be monitored. Incidents were recorded and escalated but there was a poor analysis of incidents and risk mitigation. For example, incidents on the stairs could have caused significant injury to staff and people using the service but this had not been adequately risk assessed to ensure risks were reduced as far as possible.

Concerns in regard to weight loss were acted upon but in reality, a high percent of people were either overweight or classed as obese and this was having an impact on people’s health and the risk of developing long term conditions like diabetes. We saw really poor monitoring of people’s food and fluid intake although this had recently improved. However, staff were recording ‘ate all,’ or ‘ate standard plate’ which is not sufficiently descriptive and portion size in weight reduction is important. The menu did not clearly show healthy options of food in line with people’s needs and the risks of choking, whilst known by staff was not clearly followed up when incidents had occurred.

The provider did not detect and control potential risks in the care environment. They did not make sure all equipment, facilities and technology supported the delivery of safe care.

The standards of cleanliness were poor due to carpets which acted as urine traps. The age and condition of furniture was poor, and the building was showing signs of age, making deep cleaning very difficult. A refurbishment programme was underway but the whole property was dated and in need of modernisation. This had been raised at previous inspections and had not been prioritised.

Checks of the fire alarm system were carried out, but the panel required updating as the alarm, should it go off did not connect all houses. This increased the risk of unsatisfactory evacuation particularly at night when there were only 2 waking night staff who were expected to cover more than 1 property. The risks of hoarding had been identified and people smoking in the building, making a fire more likely or spreading more easily. Individual fire risk assessment and emollient cream risk assessments were in place but not cross referenced to help ensure all staff understood the risks.

Risks from stairs could be understood both by people’s changing needs, ageing and frailty and risks from people’s behaviour. We were not assured either had been assessed regularly to identify changes in people's needs and whether the environment remained suitable

The provider did not ensure that there were enough qualified, skilled, and experienced staff. Staff had not always received effective support, supervision and development to help ensure they worked together well to provide safe care that met people’s individual needs.

People using the service and, or their relatives felt more staff at times were needed. This impacted on people’s opportunity for self-development and opportunities to go out into the community. The manager assured us that they were going to improve staffing levels and agreed they were insufficient for people's currently assessed needs. We found however over time staffing levels had not been adequately assessed because there was poor oversight of people’s needs. The dependency tool was not detailed and did not consider the environment or risks of lone working. Annual care assessments by the local authority were in many cases not up to date and daily records which could have indicated changes in people’s needs did not.

The service was made up of permanent staff on shift and the use of temporary agency staff was very infrequent which meant staff were familiar with people’s needs. However, we found a lack of support for the new manager with no deputy manager and a team leader who only worked 1 day a week. Whilst staff were supported through induction, skills for care and basic training. There was limited evidence of staff development and role specific training other than medication administration. This meant the new manager was taking it upon themselves to carry out day and night audits, supervision, and development of staff whilst seniors had oversight of care planning and risk assessments. We felt that working at pace without effective delegation was not sustainable. Although staff supervisions were up to date, we found 1 staff member with no recorded supervision and felt the supervision and oversight of staff practice had been lapsed previously. Staff recruitment records were good and contained all the necessary information. Staff interview records showed only 1 member of staff interviewing, best practice would be to have 2.

The provider did not assess and manage the risk of infection effectively. They did not detect and control the risk of it spreading and shared concerns with appropriate agencies promptly.

Despite the best efforts of the domestic team, we found poor hygiene standards across the service due to the age and condition of furniture, and fittings. This had been an issue identified in previous inspections. We found flooring in particular was not suited to people’s needs.

We found the kitchens and dining rooms grubby including sticky tablecloths and chairs and the floor in the main dining room was surrounded around the edges with rubble. This can cause a build-up of debris.

Cleaning audits were in place, but it was unclear from records how proactive staff were in supporting people with their hygiene especially those who had a history of self-neglect and or hoarding. Some people did not have access to their own sinks which might impact on their personal care giving that washing facilities were shared.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Medicines were mostly well managed by a small team of staff. There were clear protocols in place for when medicines for occasional use should be administered. Regular medication audits were carried out and we are not aware of any recent errors. Occasionally people refused medicines and records did not clearly show actions taken by staff.

All but 1 person had their medicines administered by staff and we felt this could be an area for development with staff assessing the risk and giving people more autonomy and control particularly with inhalers, creams etc.

We also found the arrangements for administration poor, with medicines being held at a central point and people coming to a hatch for their medicines. This felt like an outdated and institutionalised practice but also a trigger point for risk