Elroi Manor

Updated 15 April 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was carried out by 2 inspectors and 1 Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. The Expert by Experience spoke to people during the inspection site visit and contacted people's relatives by telephone to request their feedback.

Service and service type

Elroi Manor is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Elroi Manor is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 10 people who used the service and 10 relatives. We spoke with 8 members of staff including the registered manager. We undertook observations of people receiving care to help us understand their experiences. We reviewed a range of records. This included 4 people's care records and 9 people's medicines records. We looked at 3 staff files in relation to recruitment and records relating to staff induction, training and supervision. A variety of records relating to the management of the service and quality assurance were reviewed including accident and incident records and audits. We sought feedback from professionals who work with the service.

Updated 15 April 2023

About the service

Elroi Manor is a residential service providing personal care for up to 33 people with mental health support needs and older people some of whom are living with dementia. The service consists of one adapted building separated into 3 sections Lotus, Lavender and Lily. Each includes individual bedrooms and communal spaces with access to the surrounding gardens. At the time of our inspection there were 32 people using the service.

People’s experience of using this service and what we found

People and their relatives told us they felt safe with the care and support they or their relative received. However, despite positive feedback, we found shortfalls with fire safety, the management of people’s risks, Mental Capacity assessments and quality assurance systems which placed people at increased risk of harm.

The provider had systems in place to monitor the quality and safety of the service, however they did not identify the issues we found during the inspection.

Risks to people were not always safely managed. We identified issues relating to fire safety and people’s risk assessments.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Staff told us they felt supported; however, staff were not always trained in line with national standards.

People received their medicines safely and as prescribed, however we found some minor issues with the management of medicines. Staff followed infection prevention and control measures.

Appropriate recruitment procedures were in place to ensure staff had been assessed as safe to work with vulnerable adults.

Staff had received safeguarding training and were able to demonstrate an understanding of their responsibility to report any concerns.

People were supported to access a healthy diet.

Most people and their relatives told us they were satisfied with the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 14 June 2021) and there was a breach of regulation. At this inspection we found the provider remained in breach of regulations. This service has been rated requires improvement for the last 2 consecutive inspections.

Why we inspected

We carried out an unannounced inspection of this service on 15 April 2021. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Elroi Manor on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, consent, and good governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.