Elsenham House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating was inadequate: This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service was in breach of legal regulation in relation to Good Governance.

This service scored 36 (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 have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The provider did not always take timely action in response to risks and concerns or prioritise safe good quality care.

We did not identify a culture of learning and improvement but rather a culture where staff were not fully supported in their role. Audits were not robust in identifying shortfalls in care and there was limited inclusion of people using the service. There was not a clear collaborative process when reviewing peoples care.

Recent improvements were noted in the service since a new manager had come into post in March 2025 but without regular and consistent support, we were not assured of their success in turning the service around and improving its rating.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment, and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience, and credibility to lead effectively, and they did not do so with integrity, openness, and honesty. Whilst we recognised the skills and actions taken by the current manager they were not yet registered and had not yet had the opportunity to demonstrate how improvements would be firmly embedded and sustained over time.

Whilst the manager had implemented systems and processes to improve outcomes for people it was not clear why robust governance systems had not been put in place after each poorly rated CQC assessment. We had concerns that the staff team did not yet have the appropriate skills, knowledge and support for their roles and the manager had no deputy manager or full-time team leader to enable them to effectively delegate tasks knowing these would be completed to the necessary standard.

Provider audits had not been sufficiently robust in identifying some of the concerns we did or providing a good analysis and oversight of accidents, incidents, and safeguarding concerns to ensure the necessary steps were put in place to reduce risks. The manager had completed supervisions with staff, but this was an onerous task to sustain at regular intervals and the manager did not have oversight of additional qualifications care staff had to enable them to support them appropriately and develop their skills further. Staff spoken with told us they felt supported and valued by the new manager and said at times previously the service had been, ‘Chaotic.’ They also told us they had previous supervisions, but the ones currently were in much more depth.

People did not always feel they could speak up and that their voice would be heard.

The provider did gather feedback from people, but it was not clear how their feedback was used to improve their care and wider concerns about the service. We found some people did raise concerns with us, but the provider did not systematically use the complaints or concerns process to record and respond to these appropriately. Compliments were not routinely collated either which would help to build up a profile of the service and how it was meeting standards.

The resident of the day had been introduced where on a specific day their needs were reviewed. We found however this was not a holistic process and there were missed opportunities to fully understand every aspect of people’s needs in relation to the care that was provided.

Staff knew how to whistle blow, but we had concerns that some staff were related and working on the same shift. This might make it more difficult to raise concerns and we noted a complete lack of whistle blowers for this service despite the fact there had been some significant incidents.

The provider did not value diversity in their workforce. There was no evidence to demonstrate the provider worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff did not receive robust training to enable them to develop professionally and work in line with their job roles. Most training was online, and it was not clear how the diverse needs of staff were identified and if they had a preferred learning style and there was a lack of staff assessments of competence to ensure they could apply what they learnt.

In addition to the national shortage of care staff and local difficulties, the manager stated that local leaflets have been sent to encourage local staff to apply with little avail. The service to some extent relied on sponsorships, and the staff group was diverse with staff from overseas who provided care to an almost exclusive group of white British residents. Whilst we saw very little in terms of celebrating different culture, beliefs etc we did see that some staff were subject to racist comments and at time physical attacks and could not see how the provider supported staff and valued their negative experiences.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance, and outcomes, or share this securely with others when appropriate.

The provider had not made significant improvements and did not have an effective system in place to monitor the quality of care and drive improvements. The assessment was triggered by a potential avoidable harm incident which is still open to investigation. Since then, the local authority has visited, and the new manager has worked hard to bring about significant improvement and change.

These changes have helped to ensure there has been more effective monitoring of people’s needs, but we were concerned why effective processes were not in place earlier. Whilst care plans were good, we found other documentation sadly lacking which included daily notes that did not tell us how people were or how their needs were met in line with their care plans. Gaps in recording did not assure us risks were effectively managed.

Poor oversight of hazards and risk in the care environment were a concern and because of the age of the building the premises were difficult to keep clean which had implications for infection control.

We were concerned about the lack of analysis in regard to significant incidents which impacted on staff safety but also could result in significant injury or even death for people using the service. We could not see from the records viewed that everything was reported as it should be to the local authority safeguarding team and CQC to ensure information could be reviewed and actioned against any perceived or actual risk.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Limited feedback had been sought from health care professionals as part of the provider annual survey to help the provider improve the service. There was some evidence of joint working with other professionals and accessing health and social support for people when required.

Dependency tools did not accurately reflect people’s needs which in turn meant we were not assured either by staffing numbers of staffing competencies. For example, one person had been diagnosed with dementia and although staff had online dementia training, there was no evidence in their daily notes of collaborative working or how the person was supported to have a good quality of life.

We were concerned that the analysis of incidents did not always include a clear plan going forward or examine staff responses to extreme behaviours exhibited by some people using the service which could put people and staff at risks. Lessons learnt and reflective practice were not clearly embedded within the service which left people and staff at risk of harm.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome, and quality of life for people. They did not actively contribute to safe, effective practice and research. Over this and previous inspections we have judged the quality and effectiveness of the service as requires improvement and, or inadequate with breaches of regulation with some breaches repeated.

Whilst we took some confidence from the new manager in post we had concerns about previous shortfalls, sustainability, staffing competencies and the lack of overall support. We were also concerned about the environment and its appropriateness for people’s changing and poorly assessed needs given its limitations such as stairs etc.

The provider had failed to meet their legal requirements and demonstrate a commitment to drive the improvements in people’s care. We were not assured people lived healthy, meaningful lives or that best practice was followed.