Elsenham House

Elsenham House Nursing Home is a residential care home providing personal and nursing care to up to 36 people living with complex mental health conditions. The service also provides support to people who have a dual diagnosis of a mental health condition and a learning disability and/or autism. At the time of our inspection there were 26 people using the service. People living in the service were accommodated over five houses contained in two separate blocks. There were several communal kitchens, bathrooms, living and dining areas, the outside garden space was not separated and could be accessed from each block.

People’s experience of using this service and what we found

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

At the time of the inspection, the location predominantly supported people living with a mental health condition. However, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group.

Right Support: People did not receive the right support with medicines. This was because medicines were not always managed safely. Further improvements were needed to protect people from the risk of infection and with the management of people’s monies. Incidents that had occurred were not always reported. This meant it was difficult to be certain people and staff got the right support after an incident had occurred. People were supported by staff who knew them well and supported them to make choices. Staff took a positive approach to risk taking which helped maximise people’s control and independence. There was enough staff to support people and this helped ensure people could engage in the community. People lived in a clean environment although we noted some improvements were needed to the décor.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Right Care: Best practice in supporting people with a learning disability and/or mental health condition had not been implemented. People’s care records did not always contain accurate or complete information. People were supported by competent and trained staff who understood people’s conditions and needs. People were supported to think about how to manage their health conditions and their nutritional needs were met.

Right Culture: Improvements were still required for the governance of the service. The systems in place had not been effective in identifying and improving areas of concern. Further work was needed to strengthen the systems used to support person-centred care. The provider was open and honest about where it needed to improve. They had engaged support to help them do this from external professionals.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 13 January 2021). The service remains rated requires improvement. This service has been rated requires improvement or inadequate for the last four consecutive inspections.

We imposed conditions on the provider’s registration following the last inspection.

At this inspection we found the provider remained in breach of regulations.

Why we inspected

This inspection was prompted by a review of the information we held about this service. As a result, we undertook a focused inspection to review the key questions of Safe, Effective, and Well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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 COVID-19 and other infection outbreaks effectively.

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 and Recommendations

We have identified breaches in relation to medicines management and good governance. We have made a recommendation that the provider seeks reputable advice and guidance on implementing recognised models of support to meet the needs of the people using the service.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

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 concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.

Elsenham House Nursing Home is a ‘care home’ providing nursing care. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

There were 25 people living at the service, in receipt of nursing care at the time of the inspection.

At our last inspection on 29 February 2016, we rated the service good in all inspection domains.

Elsenham House Nursing Home consists of five houses, in two blocks. The service had a registered manager in post. ‘A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’

At this inspection on 18 and 19 July 2018, we found the evidence to support an overall rating of Inadequate.

During this inspection we identified that the service was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was in breach of the regulations for safe care and treatment, the condition of the care environment, protection of people’s privacy and dignity, adherence to the principles of the Mental Capacity Act and Deprivation of Liberty Safeguards, management of people’s nutritional and hydration needs, good governance and management of complaints, meeting the requirements of fit and proper persons and safe staffing.

During this inspection, we identified areas of concern in relation to staff competency in safe support of people experiencing mental health conditions. The cleanliness of the environment and lack of infection prevention control measures was impacting on the care people received. There were significant shortfalls in the assessment and mitigation of risks to people using the service.

The service did not have robust governance processes in place for monitoring standards and quality of care provided. Staff did not complete clinical audits in areas such as infection control and quality of care records, this was reflected in our findings during the inspection.

Staff were not implementing training and recognised clinical good practice in the care and treatment of people living at the service.

People’s records and staff’s understanding demonstrated a lack of adherence to the Mental Capacity Act and Deprivation of Liberty Safeguards. Staff did recognise the risks and support needs of people diagnosed with mental health conditions.

Low staffing levels impacted on people’s access to meaningful activities and care records lacked detail in relation to people’s hobbies and interests. There was not an up to date, daily activity timetable, and people told us there was not enough to do.

People were not consistently treated with care and compassion, and their privacy and dignity was not routinely protected.

Full information about CQC's regulatory response to any breaches of regulation found during inspections is added to reports after any representations and appeals by the provider have been concluded.

The overall rating for this service is 'Inadequate' and the service is therefore in 'Special measures'.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Elsenham House is a residential home providing nursing and personal care for up to 36 people living with mental health conditions. At the time of our inspection 22 people were living in the home.

A registered manager was in post. The registered manager was also the provider and is referred to as the manager throughout this report. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The service provided a safe standard of care for people. Staff knew how to keep people safe and understood how to make safeguarding referrals when necessary.

Risk management plans were in place in relation to each individual. These showed that people’s mental health conditions and clinical histories were well understood. Assessments were carried out to determine whether people posed a risk to their own wellbeing or that of others. Management plans were in place to reduce the level of risk as far as was possible.

There were enough staff to meet people’s needs. Robust recruitment processes were in place to ensure that staff recruited were suitable to carry out their role.

People’s medicines were well organised and people received their medicines when they needed them.

The provider had a comprehensive staff induction and training system. Staff received regular supervisions and were encouraged to seek advice when necessary from more experienced colleagues.

The service understood and applied the requirements of the Mental Capacity Act 2005 in day to day practice.

Staff were patient, caring and took time to speak with people and listen to them and any concerns they might have. People were treated with dignity and respect and were keen to remain living at the home.

People were listened to and were able to make decisions about the care they received. They also had choice about how they wanted to live their lives. People were offered the support of an advocacy service to help them express their views and make sure their voice was heard.

People’s care records were detailed and contained good information to help guide staff in how best to care and support people.

The service was well managed. The manager was positive about the people the service supported and encouraged and motivated staff. Staff felt well supported by the manager and nursing staff, Systems were in place to obtain people’s views about the service and changes were made as a result. Suitable management checking systems were in place to ascertain the quality of the service provided.

' Is the service safe?

' Is the service caring?

' Is the service responsive?

' Is the service effective?

' Is the service well led?

Below is a summary of what we found. The summary is based on our discussions with five people who used the service and four staff members. In addition we looked at three people's care and support plans.

Is the service safe?

People living at Elsenham House had varying types and levels of mental health concerns. This meant that sometimes they would decline to consent to certain aspects of their care and treatment. We found appropriate risk assessments were in place. This meant that the provider ensured that, as far as possible, people were safe in the home and that staff were safe in their working environment. Where risks to people had been identified measures had been taken to minimise or remove them. During the inspection the manager responded promptly and appropriately to a potential hygiene risk.

We found appropriate vetting of staff combined with on-going staff support, training and appraisal. This meant that the provider took reasonable steps to ensure that vulnerable adults were protected from the risk of abuse. We found that there were enough qualified, skilled and experienced staff to meet people's needs throughout the day and night. Staff were up to date with their safeguarding training.

People told us, generally, that they felt safe living at Elsenham House. Some people told us that they knew their challenging behaviour could sometimes put them at risk. They went on to say however that staff always had their best interests at heart.

During the inspection the manager dealt appropriately with an application to the local council regarding a safeguarding incident. This told us that the provider took reasonable steps to keep the relevant authorities informed of incidents where people are potentially put at risk.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to all care services. At the time of the inspection no applications had needed to be submitted. Proper policies and procedures were in place so that people who could not make decisions for themselves were protected. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service caring?

People we spoke with said that staff treated them with respect and consideration. They felt that staff listened to them and took time to explain things. People also told us that they were consulted about the care and support they received. We observed that people received encouragement, had questions answered politely and were given time to think about what it was they wanted to say or ask.

We found that the provider took steps to ensure people were involved in discussions about their daily living challenges. This included making sure people living in the home were provided with access to other sources of help and advice. As part of their recovery people were provided with access to counselling. This involved talking about their thought processes, emotions and how to deal with negativity. This told us that the provider took account of people's mental health needs as well as physical needs.

People's needs were assessed and care and support was planned and delivered in line with their individual care plans. The care plans we looked at were personalised and detailed and provided a good level of information for staff providing the care.

Is the service responsive?

The provider had a system in place to deal with concerns or complaints. We found that these had been dealt with in a timely manner. People knew how to make a complaint if they were unhappy. The complaints process was displayed in the entrance hall, making it easily accessible to people and visitors. Where shortfalls or concerns were raised these were addressed by the provider.

People told us that the provider responded to their changing needs in a timely manner. People's needs were assessed and reviewed on a monthly basis or as and when needed. Where changes occurred, the service referred to other health and social care professionals for advice and guidance if required. All changes were well documented and recorded.

One person we spoke with told us, "I get frustrated and angry sometimes but they know how to calm me down."

People who used the service and their family members or representatives, were asked for their views about the care provided and these were acted on by the provider.

Is the service effective?

People using the service that we spoke with said, or indicated to us, that the care and support provided was of good quality. They indicated their satisfaction with living at Elsenham House. However some said they sometimes found life difficult there. They went on to say that this was because they wanted more freedom. They did however accept that the care provided was in their best interests. From our observations we saw that care and support was effective and consistent. The staff demonstrated an in-depth knowledge of people living in the home.

People were supported to be as independent as possible. They were encouraged to get well and increase their independence.

We saw that staff knew the people they were supporting and caring for and that the people receiving the care and support were happy. We noted that if something was not right that staff responded quickly to resolve matters.

Is the service well led?

Views of people using the service and, where possible, their families were obtained. Staff told us that they felt supported and had received sufficient training to carry out their role effectively. They added that if they felt they needed further or additional training or support that they were confident this would be arranged by the provider. We looked at extensive training certificates for three staff members and looked at the forecasted training for 2014 / 2015. This told us that the provider took reasonable steps to keep the staff updated and trained to a high professional standard.

There were quality monitoring systems in place and audits and spot checks took place to ensure that people received a good service.

Staff were clear about their roles and responsibilities. They spoke of how they worked as a team with the needs of the person central to the work they did.

At the time of the inspection Elsenham House was undergoing a refurbishment of its existing three units. The purchase and refurbishment of an additional adjoining property was also under way. This meant that the provider took reasonable steps to maintain and improve the surroundings for people living in the home.

People living at Elsenham House had varying types and levels of mental health concerns. They consented to certain aspects of their care and treatment but would often decline to participate in some formal processes, such as care plan reviews. However, we found that consent had been sought and obtained over various issues including disclosing information and the managing and rationing of people's resources.

Care plans were detailed and we noted stepped action plans in place to meet people's needs and ensure their welfare and safety.

We found that an allegation which required reporting to adult safeguarding hadn't been reported promptly. Whilst staff were trained and a safeguarding policy was in place, internal procedures were required to ensure that concerns were raised promptly and in accordance with Norfolk Multi-Agency Safeguarding Adults Procedures.

Staff records showed that staff were appropriately vetted before commencing duties at Elsenham House.

We were satisfied that the home had an effective complaints policy in operation.

We talked with two people about their needs and found the information matched what was written in their individual care plans. People's needs were assessed, their support planned and those plans were reviewed on a regular basis.

The staff told us they were trained and understood what to do if they were concerned a person was not protected from abuse. The provider carried out checks on the suitability of potential staff before employment began showing that recruitment processes helped promote people's safety.

The records of staff training and the information shared by staff told us that the staff were supported and trained appropriately to offer support to people living in Elsenham House.

The people we spoke with told us of their involvement in choices and decisions about the quality of the service. We saw surveys for all people, professionals and families involved in the service and records showing the action taken as a result of the previous year's survey.