Ellerslie Court

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment, the rating has changed to inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, and staffing.

This service scored 34 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The provider did not effectively identify where lessons could be learned. They had no oversight or record of accidents and incidents. We were aware that some accidents and incidents had occurred, however they were not reviewed by senior staff, and no analysis had taken place.Staff team meetings did not include any documented shared learning. Staff told us they did not receive any debriefs following incidents. When we asked the registered manager to provide a log of incidents from the previous 6 months, including any learning, she was unable to provide this information at the time.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

For example, for some people, there was no evidence of preadmission assessments or medical history recorded. For others, their preadmission information was not included in their care plans or the care provided to them. Referrals to professionals were not always made where required, for example, in cases where people’s medication needs had changed.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The provider did not share concerns quickly or appropriately as required. For example, a review of accidents and incidents revealed one person had 26 falls, 5 of which had resulted in significant injuries. However, neither CQC or the local safeguarding team had been notified about any of these falls. Following our assessment, the provider submitted these notifications retrospectively and made relevant referrals to safeguarding. The registered manager at the time of the assessment told us she did not know which incidents should be reported to CQC or which required a safeguarding referral. The registered manager was unable to provide us with a log of safeguarding incidents, as this record was not in place.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them. For example, a person who required regular repositioning in relation to skin care, did not always receive this care in line with their care plan. Our observations supported this finding; the same person was left sitting in a wheelchair for over 5 hours without being repositioned. Furthermore, prescribed supplement drinks to support wound healing were not given to people as prescribed. We shared our findings with the provider following our site visit.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities, and technology supported the delivery of safe care.

For example, we observed a smoking area being used inappropriately outside a fire exit door. On both days of our site visits, we observed the same fire door propped open and used as a smoking area, which triggered the smoke alarm. This was raised with the provider and the issue was addressed immediately.

Additionally, during both site visits, we found furniture in people’s bedrooms was not secured to walls, which posed a significant risk of injury if it were to fall on someone. This was raised with the provider on both days, and the issue has since been resolved.

We reviewed documents relating to fire safety and found that actions from fire risk assessments and visits from the local fire authority had not been followed up or completed. For example, in 2022, they identified the external fire escape staircase had not been examined or assessed by a competent person to ensure it remained safe. In 2024, a fire risk assessment identified the external fire escape staircase showed signs of corrosion. At the time of our assessment, no action had been taken, and we were not assured the fire escape was safe to use. Following our assessment, the provider acted and provided evidence that work to repair the fire escape stairs was due to commence.

The provider did not make sure there were enough qualified, skilled, and experienced staff. They did not always make sure staff received effective support, supervision, and development. They did not work together well to provide safe care that met people’s individual needs.

Records showed that staff did not receive regular supervision; for example, some staff members had not received supervision since May 2024. Lack of supervisions meant managers were not able to monitor staff performance or provide appropriate support. At the time of the assessment, the registered manager confirmed that staff had not received any appraisals. Agency staff were not provided with an appropriate induction. In some cases, inductions were carried out by staff who were not qualified to do so. This contributed to incidents which impacted on the care people received. For example, an incident whereby 8 people did not receive their prescribed medication.

We observed care was not always provided when people needed it. The care we did observe was task based rather than person centred, with staff focused on completing routine tasks rather than engaging with the individual needs and preferences of people. This was due to staff shortages and how they were deployed, which was further exacerbated by the additional tasks care staff were responsible for, including social activities, kitchen work, domestic duties, and laundry.

We observed call bells were not answered in a timely way. For example, one person waited more than 15 minutes before a staff member responded to their call bell. Some people we spoke with also told us they often waited for prolonged periods of time before their call bells answered.

Since the assessment, the provider has reviewed staffing levels, employed additional staff members, and reviewed the induction and supervision process.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The home was visibly dirty. We observed dirty bedding, pillows, and toothbrushes in people’s bedrooms. There was a strong smell of urine in some areas of the home. In 2 people’s ensuite bathrooms, we noted flooring was coming away from the floor and wall, and in 1 bathroom, pools of water were gathering. This increased the risks of bacteria accumulating and contamination, placing people at risk of infection.

There were not enough domestic workers to keep the home clean. At the time of the assessment, there was 1 domestic staff member employed, who worked Monday to Friday during the daytime. On weekends and evenings, cleaning was carried out by care staff. Laundry was also completed by both domestic and care staff. Following our assessment, the provider employed additional domestic staff.

An external Infection Prevention and Control (IPC) audit completed on 4 March 2025, showed non-compliance, with an overall score of 52%. However, a further audit on 21 March 2025 showed an improved scored of 86.2%, as actions had been completed and improvements made.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

People did not always have a complete and accurate list of their current medicines, placing them at risk of not receiving their medication as prescribed. For example, where a person required medication for a life-threatening condition, this medication could not be found in the medicines trolley and there was no record written up for it. This was raised immediately with the provider, and steps were taken to contact relevant professionals, and to locate and store the medication appropriately.

Additionally, evidence was not always available to demonstrate medicines were administered on time and time specific medicines were given at the correct time. We could not be assured that topical creams were being applied safely, as records were not consistently completed. Medicines were not stored at an acceptable temperature in accordance with the provider’s medicines policy and manufacturer’s guidance. Following feedback, thermometers were ordered to ensure that medicines were stored at the correct temperature.

The provider had not completed any medication audits since October 2024. As a result, medicine related issues or failings had not been identified, and there were no effective action plans in place to mitigate or resolve these issues.