CQC report explained · a residential care home
What the CQC found at Ellershaw House Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found improvements in health and safety checks, safe recruitment, staffing, medicines management and safeguarding. Infection prevention and control arrangements were also found to be effective.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found that management systems had improved, care plans were regularly reviewed and staff understood their roles. People said the manager was approachable and listened to concerns.
What inspectors found, August 2023
Rated Good; inspectors found safe, person-centred care and improved leadership since the previous inspection.
The inspection took place on 5 and 10 July 2023. One inspector spoke with four people and eight staff, looked around the home, checked medicines and reviewed care plans, staff files and other records.
The home was rated Good overall. Safe and Well-led were both rated Good. Inspectors found that people were protected from abuse, medicines were managed safely, staffing was suitable and care plans reflected people's needs and preferences.
The home supports up to 12 people with learning disabilities or autistic spectrum disorder. Inspectors found that people were involved in their care, encouraged to be independent and supported to take part in activities, including caring for horses and using the outdoor space.
The rating improved from Requires Improvement at the previous inspection in May 2019. The home was still moving paper records to electronic systems, and inspectors said this needed better planning so the change happened smoothly.
Choice and independence
People were supported to make choices, take appropriate risks and develop daily living skills. The home offered activities and space that supported people's interests.
“Right support: People were supported to have maximum choice and control of their lives” from the report
Person-centred care
Care plans recorded people's needs, preferences, aspirations and risks. Staff knew how to support people and reviews helped keep care relevant.
“People were involved in planning their care and support.” from the report
Safe medicines practice
Medicines were received, stored, given and disposed of safely. Staff had recent training and reviews monitored whether medicines could be reduced.
“Medicines were received, stored, administered, and disposed of safely.” from the report
Improved leadership
The home had improved its checks and record keeping since the previous inspection. The manager was experienced and people felt able to raise concerns.
“At this inspection the provider had made improvements and following reviews, further planned changes were in progress.” from the report
Infection control and visiting
Inspectors were assured that infection risks were managed, protective equipment was used safely and visiting arrangements were not unnecessarily restricted.
“No unnecessary visiting restrictions were in place which ensured people enjoyed good visiting arrangements in support of their daily lives.” from the report
Electronic records transition
minorThe home was changing care, medicines, environmental and training records from paper to electronic systems. Inspectors said the management planning needed to improve so the change happened within achievable timescales.
“This would benefit from improved management planning to ensure a smooth transition within achievable time scales.” from the report
Maintenance identified during inspection
minorInspectors found that some areas needed maintenance. The home dealt with this proactively during the inspection.
“Where we identified some areas of the home required maintenance, this was proactively completed during the inspection.” from the report
- 01How far has the move from paper to electronic care, medicines, environmental and training records progressed?
- 02What checks are in place to make sure no important information is missed while records are being changed?
- 03What maintenance work was identified during the inspection, and has all of it been completed?
- 04Can you show us the previous comprehensive inspection report and explain the ratings for Effective, Caring and Responsive?
- 05How are people's views recorded and used when their care plans and personal goals are reviewed?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other key question ratings were not inspected during this visit and previous ratings were used for the overall rating. This explanation was written from the published report of 8 August 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, May 2019
Ellershaw House Limited was Rated Requires Improvement; inspectors found caring, effective and responsive support, but weaknesses in safety checks, medicines records and management oversight.
The CQC carried out an unannounced visit on 14 March 2019 and an announced visit on 22 March 2019. Two inspectors attended on the first day and one on the second. They reviewed care, medicines, accidents, staff records and quality checks, and spoke with residents, staff, the provider and others.
The home supported 10 people with learning disabilities and/or autism. Inspectors found that residents were treated with kindness and respect, had choice and control, and were supported to build independence, take part in activities and use community opportunities. Support with health, food and communication was also rated Good.
However, some health and safety checks had not been completed. Medicines competency checks and individual medicines support plans were not documented. Management records, quality checks and some safeguarding notifications were also not handled consistently. The home introduced new systems during the inspection, but these had not had enough time to show whether they worked.
The overall rating fell from Good at the previous inspection, published on 12 September 2016, to Requires Improvement. Safe and Well-led were Requires Improvement, while Effective, Caring and Responsive were Good.
Kind and respectful care
Inspectors found that staff understood residents as individuals and supported their emotional needs, dignity and independence.
“The staff treat students as individuals with warmth and genuine care.” from the report
Choice and independence
Residents were involved in decisions, set personal goals and were supported to build skills and take more control of their lives.
“Students were the lead decision-makers in their lives.” from the report
Good health support
The home worked closely with community health professionals and helped residents access appointments and support for their health.
“The provider has a fantastic relationship with the GP surgery team.” from the report
Meaningful activities
Residents took part in activities, paid and voluntary work, and opportunities designed to improve their wellbeing and independence.
“Ellershaw House encourages, facilitates and supports people to develop and enjoy the process.” from the report
Missed safety checks
seriousSome health and safety checks were not completed as often as planned, including checks relating to asbestos. The provider acted during the inspection, but new monitoring systems were still being developed.
“Health and safety checks had not always been completed or as frequently as identified by the provider.” from the report
Inconsistent management records
needs fixingRecords for residents and staff were not always up to date, and management tasks were not always completed or followed up to check quality and safety.
“Up to date records were not always kept for students or staff.” from the report
Safeguarding notifications
needs fixingThe registered manager had not submitted notifications about safeguarding incidents. The report says this was dealt with outside the inspection process.
“The registered manager had not submitted notifications of safeguarding incidents.” from the report
- 01What health and safety checks have been completed since the inspection, including the asbestos survey, and how are they monitored now?
- 02Are medicines competency checks now documented for every relevant staff member?
- 03Does each resident now have an individual medicines support plan?
- 04What changes have been made to keep resident and staff records up to date?
- 05How are safeguarding incidents now notified, recorded and reviewed?
This was a scheduled inspection covering all five CQC questions, including the premises and care provided; the previous overall rating was Good in 2016. This explanation was written from the published report of 18 May 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 Ellershaw House Limited
3 rated inspections over 7 years: the service has held its Good rating throughout.
- August 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 7 December 2010.
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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