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Elroi Manor Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 15 June 2021

About the service

Elroi Manor is a residential care home and was providing personal care to 24 people at the time of the inspection. The service can support up to 27 people. Elroi Manor provides accommodation across two floors. The ground floor is split into two sections called Lotus and Lily. Each section had private bedrooms, communal shower rooms and toilets. People can access one of three lounges, one large and two smaller, there is a large dining area located adjacent to the kitchen, and a smaller dining area in Lotus section. The ground floor has a kitchenette, indoor gardening room with raised flower beds and level access through the conservatory leads to a smoking area and extensive grounds. The registered manager’s office is located a short walk from the entrance.

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

Areas in the home were visibly dirty and had not been adequately maintained. The laundry room was being used to store soiled bedding close to freshly laundered items. We observed two staff members wearing their personal protective equipment (PPE) incorrectly. The provider was using generic COVID-19 risk assessments and so could not be sure of peoples’ individual risks in relation to COVID-19. One person who exhibited inappropriate behaviour to others living in the home, did not have a robust risk assessment and care plan to guide staff about how they should keep people safe. When the service experienced an outbreak, the deputy manager isolated with people to help prevent the spread of COVID-19.

Provider checks had not always identified shortfalls, errors and omissions we identified during our inspection. Staff spoke positively about the registered manager, deputy manager and there was a clear staffing structure. Staff and the management team provided person-centred care and we received positive feedback from professionals about care provision and partnership working. The registered manager had a vision for the future of the service and lessons were learned when things went wrong. The provider sought feedback and used different methods to communicate with stakeholders. Statutory notifications were submitted in line with requirements.

There were sufficient numbers of suitably qualified staff deployed across the service and staff were employed safely. The provider worked with the local authority safeguarding team when the need arose, and staff spoke confidently about how they would protect people from abuse. Medicines were stored, managed and administered safely.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at

Rating at last inspection:

The last rating for this service was good (published 9 August 2019).

Why we inspected

The inspection was prompted in part due to concerns received about how the provider was facilitating visitors into the home during the COVID-19 pandemic. A decision was made for us to inspect and examine those risks.

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.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.


We have found evidence that the provider needs to make improvements. Please see the Safe and Well Led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

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

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 15 June 2021

The service was not always safe.

Details are in our safe findings below.



Updated 15 June 2021



Updated 15 June 2021



Updated 15 June 2021


Requires improvement

Updated 15 June 2021

The service was not always well-led.

Details are in our well-Led findings below.