Elsenham House

We last carried out an assessment to the service on 23 August 2022 and rated it requires improvement in 4 out of the 5 key questions we inspect against including a breach of regulation 12: Safe care and treatment and a breach of regulation 17: Good governance. Since the last inspection there has been 2 changes in manager and a new manager is currently in post and has been since March 2025 but is not yet registered with CQC. Our assessment on 10 July 2025 was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of people refusing care. This inspection examined those risks. Whilst we acknowledged improvements were being made in the service, we were really concerned that the catalyst for change appeared to be the incident that had occurred and a change of manager rather than in response to the provider’s oversight for this service. Whilst the service improvements gave us some reassurance, the history of this service showed long standing, chronic issues which had reduced people’s experiences over time and our confidence in the service.

The service had been rated requires improvement and, or inadequate since 2018 with breaches of regulation which had been repeated. At this assessment we identified 5 breaches of regulation including: Person centred care, premises and equipment, staffing, safe care and treatment and good governance. Improvements introduced by the new manager were not firmly embedded. There was poor governance and oversight specifically in relation to accidents and incidents. Provider audits did not identify the things that we did and reviewing previous inspection reports the same issues were brought up time and time again, such as unsafe staffing levels particularly at night, concerns about the environment and risks associated with people’s care. We found records were poor which meant changes in people's needs could not be clearly identified.

We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. We found the provider was not meeting this guidance in terms of the support they were providing.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded. This service is being placed into special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a time within which providers must improve the quality of the care they provide.