Ellerslie Court

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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 leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The culture within the service was poor. Feedback from staff confirmed this. The provider did not have effective processes in place to demonstrate an open and transparent culture where suggestions were welcomed and acted upon. Team meetings were infrequent and mostly held on an ‘ad hoc’ basis, which meant many staff were unable to attend or contribute. The format for team meetings was not collaborative but instead dictated by management. Staff did not receive regular supervision or appraisals, and we were not provided with any evidence of staff surveys being undertaken.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment, and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience, and credibility to lead effectively, and they did not do so with integrity, openness, and honesty.

The service was not well led. The provider lacked oversight of the service and the registered manager. The day after our initial site visit, we were informed the registered manager had retired. The provider had not effectively monitored the performance of the registered manager and had not supported them with regular supervision.

The provider’s policies to ensure good governance had not been followed. For example, there was a lack of audits, which resulted in risks not being identified or addressed. The registered manager in post at the time failed to notify us about incidents and safeguarding concerns. Duringthe assessment, we found the registered manager had gaps in their knowledge and could not always provide accurate information when requested.

Following our assessment, the provider took action to recruit a new management team for the home.

People did not always feel they could speak up and that their voice would be heard.

We reviewed systems and processes for seeking and acting upon feedback from staff and found limited opportunities for staff to speak up. No staff surveys had been completed in the 12 months prior to the assessment. Of the 3 staff meetings held between January 2024 and January 2025, only 1 was planned. Minutes from team meetings did not demonstrate an open forum for staff participation and contribution; instead, discussions were led by management. One set of meeting minutes documented, it is no longer acceptable to come into the office for a chat.”

Some staff members told us they did not feel able to speak up to senior managers as they did not believe they would be supported. One staff member told us, “I don’t feel able to raise concerns.”

Since the assessment, the frequency and structure of meetings has improved within the home.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

While some staff felt supported, others did not feel reasonable adjustments were discussed or considered appropriately. Documentation provided confirmed reasonable adjustments had not been discussed, and risk assessments were not completed for some staff members with disclosed health conditions. This was raised with the provider, who confirmed they would contact each affected member of staff to discuss further.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance, and outcomes, or share this securely with others when appropriate.

Governance systems failed to assess, monitor, and drive improvement in the quality and safety of services provided, including the quality of the experience for people using the service. These systems also failed to mitigate any risks relating to the health, safety, and welfare of service users.

There was a significant lack of oversight and provider-led audits. Whilst the senior management team informed us quarterly audits were conducted, only 2 audits from the past year were provided. The audit from November 2024 highlighted serious concerns which were not addressed or followed up in a timely way Indeed, similar issues were still evident in the February 2025 audit. This indicated a continued failure to act upon identified risks.

Care plan audits had not been completed since August 2023. As a result, no audits were available for review, and ongoing issues with care planning had not been identified or addressed. Some care plans were outdated, lacked necessary detail, and did not reflect people’s current needs.

Leaders demonstrated a limited understanding of their regulatory responsibilities, such as the requirement to submit statutory notifications to the Care Quality Commission (CQC). The provider failed to report accidents, incidents, and safeguarding concerns to relevant bodies, including the CQC and local authority. Furthermore, there were no accident or incident logs maintained.

The staff training matrix showed that several mandatory online training courses were overdue. Staff had not received training in key areas such as epilepsy and mental health, despite supporting individuals with these needs. Some staff members reported feeling inadequately trained to provide appropriate care. Further, competency assessments had not been carried out, so there was no assurance that staff could perform their roles safely and effectively.

Additionally, there were concerns with workforce planning, including a lack of sufficient staffing levels to meet the needs of the service.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

There was limited evidence to show that staff, people, and their families were meaningfully involved in developing community connections or engagement opportunities. The lack of regular resident and relative meetings further contributed to this lack of collaboration.

While some individuals able to do so, accessed the community independently, those who required staff support often could not, primarily due to staffing shortages. Several family members expressed concern that their relatives were not supported to access the community, despite expressing a desire to do so. One family member highlighted that their relative was a practicing Christian but had not been supported to engage in any related community activities or religious services.

Despite these concerns, feedback from healthcare professionals was positive. They reported good working relationships with the service.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome, and quality of life for people. They did not actively contribute to safe, effective practice and research.

Staff meeting minutes did not reflect collective problem solving or reflection of improvements.

Accidents and incidents were not analysed effectively, or outcomes shared with the team, so opportunities for learning were not identified or implemented. Staff told us they did not receive effective debriefs following incidents.

Where risk had been identified, the provider failed to take appropriate and timely action in response, therefore the risks were ongoing. For example, risks identified with the external fire escape staircase were not rectified.

An action plan was in place at the time of our assessment; however, this had been formulated following contact from partner agencies and safeguarding concerns that had been raised.