CQC report explained · a residential care home
What the CQC found at Ellerslie House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2023
Inspected but not rated; inspectors found improvements, while the home's previous overall rating remains Requires Improvement.
This was an unannounced targeted inspection on 4 April 2023. The inspector reviewed care records for five people and other management records, and spoke with managers.
The inspection only checked parts of Safe and Well-led. Inspectors found that the home had improved safety checks, risk assessments, care records, medicines systems and quality monitoring. They said the home was meeting the requirements of the Warning Notices issued in August 2022.
The home was not given new ratings at this visit. The previous overall rating remains Requires Improvement because this inspection did not assess every part of the service.
Better risk information
Risk assessments and care plans had been reviewed and contained clearer, personalised guidance to help staff keep people safe.
“The provider had reviewed and updated all risk assessments, which now contained sufficient information for staff to identify warning signs and take action to avoid risks” from the report
People's activities
People were supported to follow their interests and take part in activities inside and outside the home.
“Care records showed people were supported with a wide range of inside and outside activities that reflected their interests.” from the report
Medicines records
The medicines systems reviewed were complete, with checks and protocols for medicines taken when people went out.
“There were no gaps or errors in the medicines administration records (MARs) we reviewed.” from the report
Action tracking
The home had clearer systems for identifying, assigning and completing improvements from audits and management reviews.
“Records we reviewed showed this was operating effectively.” from the report
Family involvement
The home had increased opportunities for families to give feedback and take part in care plan reviews.
“The provider had put in place improved and expanded processes for engaging people's families and staff.” from the report
Not a full inspection
needs fixingThe visit did not reassess all parts of Safe or Well-led, and did not assess Effective, Caring or Responsive. The previous overall rating therefore remains Requires Improvement.
“Targeted inspections do not change the rating from the previous inspection.” from the report
Previous regulatory failures
seriousThe previous inspection found failures involving safe care, risk management, records, governance and listening to people and families. The current visit found that the Warning Notice requirements had been met, but the full service rating was not changed.
“At our last inspection we found 8 instances where the provider had failed to support people safely.” from the report
- 01How are you checking that the updated risk assessments and care plans remain accurate for my relative?
- 02How do you make sure actions found through audits are completed and do not remain outstanding?
- 03How will my relative and our family be involved in care plan reviews and service feedback?
- 04How are medicines checked when people take them out of the home?
- 05When will the next comprehensive inspection assess the areas not covered by this visit?
This was a targeted inspection of specific parts of Safe and Well-led to check Warning Notices; the other areas were not assessed and the previous ratings carry over. This explanation was written from the published report of 18 May 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, August 2022
Rated Requires Improvement; inspectors found risks, poor records and weak leadership, with warning notices issued.
This was an unannounced focused inspection on 29 June, 1 July and 5 July 2022. Inspectors looked at Safe, Effective and Well-led because of concerns about safety and leadership. Caring and Responsive were not inspected, so their earlier ratings were carried forward.
The home was not always safe. Risk assessments and emergency evacuation plans lacked important details. Safety checks were missed, records were incomplete and there was heavy reliance on agency staff. Medicines were generally managed safely, but some administration records had gaps that audits had not found.
Care was not always person-centred or least restrictive. Inspectors found weak mental capacity assessments, limited evidence that people were involved in decisions, and care plans that were out of date or inconsistent. The environment was not always clean or homely, although some clutter was removed during the inspection.
The overall rating remained Requires Improvement, as did Safe, Effective and Well-led. The home had also been rated Requires Improvement at the previous inspection, and inspectors said enough improvement had not been made. The provider remained in breach of regulations 11 and 17, and was in breach of regulation 12.
Improved medicines storage
Medicines and records were stored securely and staff had completed relevant medicines training. The main remaining problem was that audits did not find gaps in administration records.
“All staff had received relevant training to enable them to administer medicines safely.” from the report
Access to health care
The report records that people had used local health services, including GPs, dentists and opticians.
“People had accessed GPs, dentists and opticians and this was recorded in their care plan.” from the report
Community access
The home's location allowed people to take part in the local community, although this usually required a short car journey.
“The service was located so people could participate in the local community following a short car journey.” from the report
Incomplete risk information
seriousSome risk assessments did not explain the risks or the exact support staff should provide. This included cooking, swimming, choking, diabetes and emergency evacuation.
“There was a risk new or unfamiliar staff would not know how to support the person safely.” from the report
Restrictive support
seriousInspectors saw staff repeatedly holding and redirecting one person, even when the person was alone in a large enclosed garden. The report says this restricted the person's freedom.
“This meant the person's freedom was constantly restricted.” from the report
Weak mental capacity records
seriousSome assessments did not show how the person was consulted, how information was communicated or who made the decision. This meant the home could not demonstrate that it was following mental capacity law.
“There was no evidence any attempt was made to consult with the person.” from the report
Poor quality monitoring
seriousThe provider's audits and governance systems did not identify or address important problems. Accident and incident records were not always detailed, and lessons were not reliably learned.
“Quality assurance systems and processes did not identify, or address issues found at inspection.” from the report
Staffing and support
needs fixingThe home relied heavily on agency staff, and the manager spent much of their time covering care shifts. Staff did not receive regular supervision, and some required training was incomplete.
“Agency staff were being heavily relied on at Ellerslie House.” from the report
Environment and records
needs fixingSome areas needed cleaning and communal spaces were not always homely. Paper and electronic care records did not always match, creating a risk that staff might follow outdated information.
“Some areas of the home were not always clean, for example we observed carpets which required hoovering and areas of the home which required dusting.” from the report
- 01What has changed since this inspection to make risk assessments and personal emergency evacuation plans detailed and up to date?
- 02How do you check that agency staff understand each person's health needs, including choking risks, diabetes and other specific conditions?
- 03How are mental capacity assessments and best-interest decisions completed, recorded and reviewed with the person?
- 04How do you monitor physical interventions and learn from accidents, incidents and safeguarding concerns?
- 05How are people, relatives and staff now asked for feedback, and how are they told what action was taken?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 30 August 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.
Every inspection of Ellerslie House
2 rated inspections over a year: the service has held its Requires improvement rating throughout.
- May 2023Inspected but not ratedcurrent ratingSafe: Inspected but not ratedWell-led: Inspected but not rated
- August 2022Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2022Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- March 2020
Registered with the Care Quality Commission on 13 March 2020.
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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26 live-in carers within about an hour of Hampshire
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 £1,020 to £1,260 a week. 23 can care for a couple. 14 years' experience on average.
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