Ellerslie Court

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment, and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment, the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support, and outcomes.

The service was in breach of legal regulation in relation to consent to care and treatment.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing, and communication needs with them.

Staff had not ensured all people’s care plans and risk assessments were updated regularly and contained accurate information. For example, care plans for 1 person had not been reviewed since November 2024, and their choking risk assessment did not contain clear information about the specific risks they faced.

Furthermore, care plans were not always in place for people with specific needs. Without this information, staff members would not know how to manage their diagnosis or provide appropriate support to meet the person’s needs.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

For example, one person’s care plan stated they needed to be monitored at times as they had ‘a tendency not to eat enough and weight loss becomes a concern.’ They had a MUST score of 1, which indicates medium risk. The Malnutrition Universal Screening Tool (MUST) was designed to help identify adults who are underweight and at risk of malnutrition. National guidance states that for people at medium risk in a care home, the MUST screening should be repeated at least monthly (A Guide to the ‘Malnutrition Universal Screening Tool’ (BAPEN). However, for this person, the MUST score had not been reviewed since September 2024. They had lost 2.1kg between January and February 2025. We also observed the same person was not offered breakfast on the day of our site visit. We discussed this with the provider who assured us that action would be taken immediately to update people’s care records.

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

Staff members we spoke with discussed the difficulties they had with staffing levels and the use of agency staff. They provided examples of situations where shifts were primarily run by agency staff, and times when agency staff did not know how to do their job. One staff member told us a concern was, “Agency struggling with stomas, and regular staff having to step in and do it.”

Furthermore, during our site visit, we observed some agency staff standing around and appearing unsure of what they were supposed to be doing. They had to be directed by regular staff on several occasions.

However, feedback from some professionals was positive. They told us communication with staff at the home was always good and appropriate channels for referrals were followed.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice, and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

Staff had not received appropriate training to meet the needs of all people who lived in the home. Specifically, staff had not completed training in epilepsy, mental health, learning disabilities, positive behaviour support or substance abuse, despite supporting people who had these needs. 3 staff members did not feel they had been provided with enough training to support the needs of all people.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Records were not sufficiently robust to evidence staff were monitoring people’s care. For example, we observed one person had a bruise on their right arm; however, this had not been documented anywhere in their care record or body map. This was raised with the provider who stated they would ensure the records were updated.

Furthermore, we found gaps in repositioning charts and gaps in prescribed supplement drinks for one person who required these to promote wound healing, which suggested they had not been provided.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making decisions on behalf of people who may lack the capacity to do so for themselves. The Act requires that as far as possible, people make their own decisions and are supported to do so when needed. When they lack capacity, any decisions made on their behalf must be in their best interests and as least restrictive as possible. However, mental capacity assessments and best interest decisions were not in place as required. For example, people's capacity to consent to restrictions upon their freedom, such as assistance with personal care and the use of sensor equipment, was not always assessed.

Some people were deprived of their liberty without the legal authority to do so. Deprivation of Liberty Safeguards (DoLS) had not all been applied for or had expired for people who required them. For example, one person’s DoLS authorisation had expired on 25 July 2024 and was not reapplied for until 28 February 2025. This person had restrictions placed upon them between July 2024 and February 2025 without the legal authorisation in place.

Four staff members we spoke with were unable to tell us who was subject to DoLS in the home or what restrictions people had in place.

Since the assessment took place, consent for all people has been reviewed and applications for DoLS made where required.