CQC report explained · a residential care home
What the CQC found at Ellacombe
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were not always protected from avoidable harm. Inspectors found repeated problems with skin care, risk assessments, fire safety, nutrition and some medicines records.
- Effective?
- Requires improvement
- This key question was not inspected during this focused visit. Its previous rating was carried forward to calculate the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Inspectors did observe kind and meaningful interactions and received mainly positive feedback.
- Responsive?
- Requires improvement
- This key question was not inspected during this focused visit. Its previous rating was carried forward to calculate the overall rating.
- Well-led?
- Requires improvement
- Management systems had improved but did not identify all the risks and shortfalls found by inspectors. The home remained in breach of Regulation 17.
What inspectors found, October 2023
Ellacombe rated Requires Improvement; inspectors found kind care and enough staff, but repeated safety and management weaknesses increased the risk of harm.
This was an unannounced focused inspection on 20 July and 3 August 2023. Inspectors spoke with people, relatives, staff and managers. They reviewed care records, medicine records, staff files and the home's quality checks.
The home was not always safe. Inspectors found gaps in skin checks and repositioning records, missed care such as showers, inconsistent nutritional support, unsafe access to some items, and weaknesses in fire safety and medicines records. The home remained in breach of Regulation 12.
The home was also not always well-led. Its audits had improved but had not identified all the problems found by inspectors, so it remained in breach of Regulation 17. The overall rating stayed Requires Improvement, as did Safe and Well-led. The other three key questions were not inspected during this visit and their previous ratings were used.
Enough trained staff
Inspectors found enough staff to meet people's assessed needs. Recruitment checks, training and competency checks were in place.
“There were enough staff to safely meet people's assessed needs.” from the report
Kind interactions
People and relatives mostly gave positive feedback, and inspectors saw staff treating people kindly and meaningfully.
“We observed kind and meaningful interactions between people and staff during our inspection.” from the report
Improved mental capacity practice
The home had made sufficient improvements and was no longer in breach of the consent regulation. Capacity assessments and legal authorisations were generally recorded.
“We found sufficient improvements had been made, and the service was no longer in breach of regulation 11.” from the report
Infection control
Inspectors were assured about infection prevention, equipment and outbreak arrangements. People and relatives also gave positive feedback about cleanliness.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Responsive management
The manager and staff responded to inspection feedback and made changes. Staff meetings and incident reviews were used to support learning.
“The registered manager was responsive to our feedback.” from the report
Skin care and repositioning
seriousSome people were not repositioned as often as health professionals required. Skin checks and records had gaps, increasing the risk of pressure damage.
“People were not being repositioned in line with the frequencies stipulated by health care professionals to prevent them from developing skin pressure damage.” from the report
Unsafe access to items
seriousSome people could enter bedrooms and reach items such as lighters, tobacco, alcohol, food and craft materials without enough assessment or supervision.
“We also found batteries, craft, and gardening items, as well as food and alcohol not stored securely.” from the report
Medicines records
seriousCream application records had missing signatures. Guidance for medicines hidden in food or drink did not say what food or fluid could be used safely.
“Topical medication administration records contained gaps in staff signatures.” from the report
Nutrition and personal care
needs fixingRecords did not consistently show that additional calories were provided. Some people went up to 12 days without a bath or shower when their care plan required weekly showers.
“Where people required additional calories added to their diet, recording of this was inconsistent.” from the report
Quality checks missed problems
seriousThe home's audits had improved but still failed to identify several safety and care shortfalls. This meant management oversight was not reliable enough.
“We still found some areas of improvement in the quality and standards of people's care which had not been identified through the provider's own audits and checks in place.” from the report
- 01How are you now recording and checking repositioning and skin condition for people at risk of pressure damage?
- 02How do you make sure additional calories are provided and recorded when a person's food intake is poor?
- 03What has changed to keep lighters, tobacco, alcohol, food and other potentially risky items secure?
- 04How do you check that creams are applied consistently and that covert medicines have suitable written instructions?
- 05What does your action plan say, and how will you show that your audits now identify these problems?
This was a focused inspection of Safe and Well-led only; the other key-question ratings were carried over from the previous inspection. This explanation was written from the published report of 20 October 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2020
Rated Requires Improvement; inspectors found kind care, but safety, equipment, consent records and management checks were not reliable enough.
This was a scheduled, comprehensive inspection. Inspectors visited on 11 and 12 November 2019. They spoke with people, relatives, managers and staff, observed care and medicines, and checked care records, medicine records, staff files and quality checks.
The home was not always safe. Inspectors found risks from unsecured items, unsafe or broken windows, incomplete repositioning records and medicines being prepared incorrectly. Two sets of weighing scales were broken, so some people had not been weighed since September 2019.
People were treated with kindness and respect. However, records did not always show that people's needs and healthcare advice were being followed. Feedback about activities was mixed. Management audits had not found several of these problems.
The overall rating was Requires Improvement. Safe, Effective, Responsive and Well-led were all rated Requires Improvement. Caring was rated Good. The home was previously rated Good overall in 2017, so the overall position had worsened.
Kind and respectful staff
Inspectors observed caring interactions. People and relatives gave mostly positive feedback about the care.
“We observed kind, caring and polite interactions between people and staff.” from the report
Health care links
The home worked with local health and social care professionals. People were supported to attend health appointments.
“The service had a good working relationship with the local GP practice, pharmacy and social care teams.” from the report
Personalised care records
Records included people's preferences, likes, dislikes and personal histories. They were reviewed and updated after incidents or changes in risk.
“Care records were written in a person-centred way, detailing people's preferences, likes and dislikes.” from the report
Opportunities to give feedback
People, relatives and staff could share their views through meetings, questionnaires and care reviews.
“The service held regular community meetings for people to raise concerns or contribute ideas to the running of the service.” from the report
Safety risks
seriousInspectors found unsecured items, unsafe windows and records that did not show recommended repositioning was taking place. These issues were considered a risk of harm.
“Risks to people and the care environment were not well managed. This placed people at risk of harm.” from the report
Medicines errors
seriousSome medicines were crushed when they should not have been, or should first have been dissolved in water. There were also missing stock checks and an incorrect controlled drugs record.
“Two of the medicines that were crushed should have been dissolved in water prior to administration and for one of these it clearly stated this medicine must not be crushed.” from the report
Broken equipment
seriousBoth sets of weighing scales were broken, so some people had not been weighed for several months. This affected monitoring of weight and pressure care needs.
“The service did not ensure all equipment was maintained or replaced.” from the report
Consent paperwork
seriousRecords did not always correctly show who had legal authority to make decisions. Required checks and professional involvement were missing for some decisions about care and medicines.
“Staff did not consistently work within the principles of the Mental Capacity Act (2005).” from the report
Weak management checks
seriousAudits did not identify several problems with safety, equipment, medicines and records. The home was asked to improve its governance systems.
“The governance systems and processes in place were not always protecting people from risk of harm.” from the report
Limited activities
needs fixingPeople and relatives gave mixed feedback about the amount of activity and stimulation available. Some people felt there was not enough to do.
“We received mixed feedback on the level of activities available at the service.” from the report
- 01What evidence can you show that the safety risks from windows and unsecured items have been fully fixed?
- 02How do you now check that medicines are stored, prepared and recorded correctly?
- 03Have the weighing scales and other equipment been repaired or replaced, and how are equipment checks recorded?
- 04How do you check that Mental Capacity Act assessments, best-interest decisions and lasting power of attorney records are accurate?
- 05What activities are now available for people living with dementia, including one-to-one activities?
This was a scheduled, comprehensive inspection covering all five CQC questions, and the report says the home was previously rated Good overall in 2017. This explanation was written from the published report of 1 February 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Ellacombe
4 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- October 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- April 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- April 2011
Registered with the Care Quality Commission on 25 April 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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13 live-in carers within about an hour of Norfolk
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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