CQC report explained · a nursing home
What the CQC found at Ellenborough Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed, medicines were managed safely, safeguarding systems were in place and the home was clean. They noted an out-of-date fire risk assessment and that repositioning was not always recorded within exact time frames.
- Effective?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward into the overall rating.
- Responsive?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward into the overall rating.
- Well-led?
- Good
- Inspectors found improved audits and governance systems, supportive leadership and care records that included people's needs and preferences.
What inspectors found, July 2022
Ellenborough Nursing Home rated Good; inspectors found safer medicines management and stronger oversight, but noted an out-of-date fire risk assessment and some recording issues.
This was an unannounced focused inspection on 23 June 2022. Inspectors checked Safe and Well-led. They spoke with people living there, visitors, staff and the manager, and reviewed care records, safety checks, medicines records and service audits.
The home was rated Good for Safe and Well-led. People said they felt safe, medicines were managed safely, risks were assessed, and staff had friendly relationships with residents. Inspectors also found better systems for checking care, medicines, maintenance and staff training.
The previous inspection in 2019 rated the service Requires Improvement and found two legal breaches. This inspection found enough improvement for the home to be no longer in breach. The overall rating became Good, although the other three question ratings were carried forward because they were not inspected this time.
People felt safe
People and relatives told inspectors they felt safe and confident that residents were cared for well. Staff had safeguarding training and knew how to report concerns.
“People told us they felt safe at the service.” from the report
Medicines were safer
Inspectors found that medicines were stored, checked and given safely. Staff followed prescribers' guidance and sought clarification when needed.
“Medicines were managed safely.” from the report
Better oversight
The home had improved its audits and checks since the previous inspection. These covered medicines, care records, equipment, falls, weights and maintenance.
“Since our last inspection the service had improved their governance systems.” from the report
Kind relationships
Inspectors observed warm and friendly interactions. People and relatives spoke positively about staff's kindness and helpfulness.
“We observed warm and friendly relationships between staff and people living at the service.” from the report
Fire risk assessment was out of date
needs fixingThe fire risk assessment was not current when inspectors visited. The manager had taken action to organise a new assessment.
“We found the fire risk assessment for the service was out of date, however the registered manager has now taken action to organise a new assessment.” from the report
Repositioning records
needs fixingRecords did not always show repositioning happening within the exact required time frames. The electronic system allowed a margin of up to one hour, which the manager said would be reduced.
“Repositioning had not always been recorded as occurring within exact time frames.” from the report
Fewer staff in the evenings
minorOne person said there were not so many staff on in the evenings. Inspectors nevertheless found that staffing levels were sufficient to meet people's care needs.
“There are not so many staff on in the evenings.” from the report
- 01Has the new fire risk assessment been completed, and can we see what actions came from it?
- 02How will you make sure repositioning is completed and recorded at the correct times?
- 03How many staff are usually on duty in the evenings, and how do you decide whether this is enough?
- 04What were the ratings for Effective, Caring and Responsive at the previous inspection?
- 05How will you continue checking medicines, care records and other safety risks?
This was a focused inspection of Safe and Well-led only; the other three ratings were carried forward from the previous inspection. This explanation was written from the published report of 22 July 2022 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, October 2019
Rated Requires Improvement; inspectors found kind, skilled care but unsafe medicines practices, incomplete care records and weak checks on quality.
This was an unannounced inspection on 27 August 2019. Inspectors spoke with 10 people, two relatives and nine staff. They reviewed care records, medicine records, incident records, training information, complaints and quality checks.
People were treated with kindness, dignity and respect. Staff knew people well, had suitable training and worked with health professionals. People and relatives gave positive feedback about the care, food, activities, staffing and management.
The main concerns were about safety and record keeping. Some medicine records were inaccurate, some medicines were not given exactly as prescribed, and records did not always show that people had received care such as repositioning or fluid monitoring.
The overall rating was Requires Improvement. Effective, Caring and Responsive were rated Good. Safe and Well-led were rated Requires Improvement. The previous overall rating was Good, published in January 2017.
Kind and respectful care
People and relatives gave positive feedback. Inspectors observed friendly interactions and found that people's privacy, dignity and choices were respected.
“People were supported by staff that were caring and treated them with dignity and respect.” from the report
Skilled staff
Staff received ongoing training, supervision and appraisals. Inspectors found that staff understood their roles and had the knowledge needed to support people.
“People were well cared for by staff that had the knowledge and skills to meet people's needs.” from the report
Personalised care
Care plans included personal information and staff knew people well. People and relatives said they were involved in decisions about care.
“Care plans were person centred, individualised and relevant to the person.” from the report
Good safeguarding and staffing
Staff had safeguarding training and understood how to report concerns. Inspectors found staffing levels were adjusted when people's needs increased.
“People were protected from potential abuse and avoidable harm by staff that had received training in safeguarding.” from the report
Medicines were not always managed safely
seriousSome medicine records contained wrong room numbers or inaccurate information. Some prescribed antibiotics were not given according to the stated timing instructions, and the medicine policy did not cover all important areas.
“Some medicines were not being administered in accordance with the prescriber's instructions and the providers current policy was not comprehensive in some areas.” from the report
Care records did not always show care given
seriousFluid charts were not always totalled or escalated when intake was low. Records also did not always show that people who needed regular repositioning had received it.
“Where people had been assessed as requiring regular repositioning to reduce the risk of pressure sores some records were inaccurate or incomplete.” from the report
Quality checks missed risks
seriousThe home's own and provider-level audits did not identify the medicines, recording and air mattress problems found by inspectors.
“Both local internal and provider level audits had not been effective in identifying these risks.” from the report
End of life plans lacked detail
minorSome end of life information was recorded, but the home had not explored personal preferences such as who people wanted with them or their preferred music.
“The service did not currently explore people's specific preferences to be actioned or taken into consideration at the end of their lives.” from the report
- 01What changes have been made to make sure medicines are given exactly as prescribed and medicine records show the correct room and treatment details?
- 02How do you now check and record repositioning, fluid intake and escalation when someone drinks too little?
- 03How do you make sure air mattresses and other equipment are set correctly for each person?
- 04What new audits or checks have been introduced so that problems are found before they put people at risk?
- 05How will you record each person's personal preferences for end of life care?
This was an unannounced planned inspection that assessed all five CQC questions and included the premises, care, medicines, records, staff and management systems. This explanation was written from the published report of 10 October 2019 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 Ellenborough Nursing Home
3 rated inspections over 5 years: the service has held its Good rating throughout.
- July 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- January 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 27 January 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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