• Care Home
  • Care home

Elstow Manor

Overall: Requires improvement read more about inspection ratings

Elstow Manor, Bedford Road, Bedford, MK42 6FZ (01234) 676766

Provided and run by:
Hamberley Care (Wixams) Limited

Important:

We served a Section 29 Warning Notice on Hamberley Care (Wixams) Limited on the 20 August 2024 for failing to meet the regulations relating to, person-centred care, safe care and treatment and good governance at Elstow Manor.

All Inspections

During an assessment under our new approach

We carried out this assessment from 23 July to 1 August 2024. We visited Elstow Manor on 23 July to 1 August 2024. This assessment was carried out following concerns shared with us about people’s safety. Elstow Manor is a residential care home with nursing. The service provides support to people living with dementia, people with nursing needs and people with personal care needs. We looked at all quality statements from the safe, effective, and well-led key questions. We found areas of concern and good practice. The scores for the caring and responsive areas are based on the key question ratings from previous inspections. Our overall rating of this service remains requires improvement. We found 3 breaches of legal regulations in relation to safe care, person-centred care, and governance arrangements. We found that the provider's systems had shortfalls in ensuring people's health and safety. There were concerns regarding incident reporting, managing medicines, and care planning. People's needs were not always well assessed and planned for, and their nutritional and hydration needs were not consistently met. However, the provider had appropriate safeguarding policies and procedures, and the environment was safe and well-maintained. Staff and leaders were seen as caring and approachable, with positive feedback about their approach. Staff worked with external professionals in relation to people's health and care needs.

21 October 2022

During a routine inspection

About the service

Elstow Manor is a residential nursing home providing personal and nursing care to up to 80 people. The service provides support to people living with dementia as well as some physical health conditions. At the time of our inspection there were 38 people using the service.

People were supported in a purpose built building across three floors. The top floor was currently unused. There were lounges, dining areas and other communal spaces on each floor. One floor had a cinema and on other floors there was a hairdressing salon and bistro. There was a garden area which included a small play area for visiting children. There was an office onsite and the layout was designed in a way to support people with mobility needs to freely access any area.

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

People were supported to safely administer their medicines and agreed with staff and medical professionals what time they would like to take them. However, the registered manager was taking action to improve the administration records and systems for managing excess stock of medicines.

People were supported by trained staff in all aspects of their daily life. This included going out of the home, maintaining contact with friends and relatives, having meals and drinks, socialising and meeting their health needs. However, people felt that staffing shortages had an impact on some people’s experiences of their care. The registered manager was in the process of a recruitment drive to help with the continuity of care.

People were able to speak with the registered manager when they had concerns and told us they acted very quickly to resolve them. The registered manager monitored all aspects of people’s care but medicines audits were not always effective at identifying areas for improvement. The registered manager was aware of this and taking action to improve systems and processes.

People told us they felt safe living at Elstow Manor. They liked the staff and told us staff treated them well, were kind and met their needs. Staff knew how to keep people safe and what to do if they had any concerns. People told us living at Elstow Manor was like living in a five star hotel.

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.

The registered manager made sure all staff and visitors followed the latest government guidance for reducing risks about COVID-19 and the spread of infection. Staff had received additional training on this topic to ensure they could keep people as safe as possible.

People had access to health professionals who worked closely with the staff and management team to ensure all health concerns were looked into straight away. The nursing staff were able to observe and record basic health observations such as blood pressure and oxygen levels to help professionals get the right information and monitor people’s well-being quicker.

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

Rating at last inspection

This service was registered with us on 16 July 2021 and this is the first inspection.

Why we inspected

This inspection was planned based on the date the service was registered with the CQC. 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.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.