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Ellenborough Nursing Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 10 October 2019

About the service:

Ellenborough Nursing Home provides accommodation with nursing and personal care for up to 27 people. When we visited, 22 people lived there, however one person was in hospital.

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

People were supported by staff that were caring and treated them with dignity and respect. Staff understood the needs of the people they supported well and knew them as a person. All the feedback we received from people and their relatives was positive.

Not all risks in relation to the management of medicines were managed safely and we found errors with records that placed people at risk. Some medicines were not being administered in accordance with the prescriber’s instructions and the providers current policy was not comprehensive in some areas.

Where people were assessed as requiring specified care, for example with repositioning to reduce pressure ulcer risks and the monitoring of fluid intake, records did not support that this care had been provided. Whilst it was not evident this had resulted in impact for people, people were at risk of not receiving care in line with their assessed needs.

Risks of abuse to people were minimised. Staff had received safeguarding training and the service had appropriate safeguarding systems and processes. Staff understood safeguarding reporting processes. There were effective systems that ensured the service and environment were safe. Health and safety checks, together with effective checks of the environment were carried out by dedicated staff.

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. There were systems in place that ensured people who were deprived of their liberty were done so with the appropriate legal authority.

People were supported by staff who had the skills and knowledge to meet their needs. Staff felt supported by the registered manager. Staff understood their role and were confident when performing it through a continual training package. Staff at the service worked together with a range of healthcare professionals to achieve positive outcomes for people. People’s care plans were personalised with the information they held, and this helped staff to understand people well.

Since 2016 onwards all organisations that provide publicly funded adult social care are legally required to follow the Accessible Information Standard (AIS). The standard was introduced to make sure people are given information in a way they can understand. There was evidence that where needed the service supported people to communicate and understand through the use of pictorial aids.

People's concerns and complaints were listened to and responded to. Accidents, incidents and complaints were reviewed to learn and improve the service where needed. People and their relatives commented positively about the registered manager and the quality of care their family member received. No concerns were raised about the quality of care provided.

Governance systems included audits and regular checks of the environment to ensure people received good care. These were completed at local and provider level; however, these were not effective in identifying poor recording or concerns with medicines we found. Whilst it was not evident this had any impact on people, it did not evidence a fully effective governance system was in operation and placed people at risk.

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 January 2017)

Why we inspected:

This was a planned inspection based on the previous rating.

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 and wi

Inspection areas


Requires improvement

Updated 10 October 2019

The service was not always safe.

Details are in our Safe findings below.



Updated 10 October 2019

The service was effective.

Details are in our Effective findings below.



Updated 10 October 2019

The service was caring.

Details are in our Caring findings below.



Updated 10 October 2019

The service was responsive.

Details are in our Responsive findings below.


Requires improvement

Updated 10 October 2019

The service was not always well-led.

Details are in our Well-Led findings below.