Ellis House

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. This is the first assessment for this service. This key question has been rated Good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 promoted a proactive and positive safety culture based on openness and honesty. Lessons were learned, helping the service identify and embed good practice.

Relatives told us they felt people were safe living in the home. One relative said, “I feel my family member is safe when I visit. They always seem very happy and can’t wait to get back there whenever they visit me.”

Following incidents involving distressed behaviour, staff told us how the manager held debrief sessions with them to review what happened and explore different approaches. One staff member said, “There is no judgement. It’s a relaxed conversation where we can get advice from the registered manager.” Another staff member told us, “Incidents are investigated by the manager on duty and looked at by more senior staff too. We check the person after an incident and ask them if they are ok and watch for signs that they may not be ok. We will also have a talk with the staff involved to see how they are and reflect on whether we could have done anything differently.”

Incidents, accidents and lessons learned were shared in team meetings and handovers.

The provider worked with people and healthcare partners to establish safe systems of care, where safety was managed and monitored. Continuity of care was maintained, including when people moved between different services.

Relatives told us people moved into the home safely. One relative said, “[Person’s name] had a very well organised transition to Ellis House from their previous home. The management team took a lot of time and care to understand [Person’s] needs and reduce any anxiety linked to the change. They listened to points we raised about adjustments needed, such as changes to their room or preferred activities, and they were reassuring and supportive at all times.”

Staff described how they supported people to move into the home safely. The manager explained people were offered visits in advance, and visual aids such as photographs were used to help the person become familiar with their new environment.

A visiting professional told us, “Since [person] moved from the family home to Ellis House, staff have been fantastic, providing exceptional care and promoting independence at every step, while also supporting the family during this difficult transition.”

Records confirmed people’s needs were assessed before moving into the home and reviewed regularly.

The provider worked with people and healthcare partners to understand what being safe meant to each person and the best way to achieve safety. Staff focused on improving people’s lives while protecting their right to live in safety. Concerns were shared quickly and appropriately.

Easy read materials were available to help people understand what abuse is and how to raise concerns. Easy read is a way of showing written information using images and simplified text to make it easier to understand.

Relatives told us people received safe care and the provider kept them informed about safeguarding issues. One relative said, “I have not had to raise anything myself but there have been some minor safeguarding issues. The provider raised these themselves, told me about them and dealt with everything very professionally.”

Staff understood their duties and responsibilities when keeping people safe. They explained how they would raise concerns with the manager and escalate issues when needed. One staff member said, “Safeguarding training gave me the knowledge to watch for signs of concern, and the right path to follow when reporting any concerns.”

Safeguarding policies were in place and accessible to staff, who were able to tell us where they could find them. The provider raised safeguarding concerns with the local authority when needed.

Where people lacked capacity for specific decisions, detailed mental capacity assessments were completed, and appropriate Deprivation of Liberty Safeguards (DoLS) authorisations were in place. People can only be deprived of their liberty to receive care and treatment with the correct legal authority. In care homes, this is done through the DoLS process within the Mental Capacity Act 2005 (MCA). We reviewed how the service applied MCA principles and how DoLS were managed. We found people without capacity to agree to their care and treatment had appropriate legal safeguards in place.

The provider worked with people to understand and manage risks in a holistic way. Staff delivered care in a safe and supportive manner while enabling people to do the things that mattered most to them.

Relatives told us staff encouraged people to try new experiences to build confidence. One relative said, “They will trial going to places to build up [person’s] confidence.”

Staff described how they promoted positive risk taking. One staff member explained people should not be stopped from taking part in any activity, so long as risks were assessed and managed safely. Another staff member shared an example, they said, “One person prefers to eat unhealthy foods. We [staff] encourage them to eat healthier foods but at the end of the day we cannot force them, so if they take a bag of crisps, then we have to respect their decision even if it is not the healthiest choice for them.” We observed staff encouraging people to choose their own activities and supporting them to access their community.

Risk assessments were in place to help staff manage risks and follow clear guidance. Risks linked to people’s health were monitored and managed safely.

The provider identified and controlled potential risks in the care environment. Equipment, facilities and technology were used in ways which supported the delivery of safe care.

One relative told us, “Staff are meticulous with their safety checks around the home.”

Staff explained how fire safety checks were carried out regularly. People were encouraged to take part in fire evacuation tests.

The environment was adapted to meet people’s needs. Sensory areas were available inside the home and in the garden to support people with sensory needs. Bedrooms were personalised in line with people’s preferences, interests and personalities.

Internal and external health and safety checks were completed to monitor the safety of the premises, utilities and equipment.

The provider ensured there were enough staff on duty to support people safely. However, staffing arrangements require improvement because not all staff had completed all of their mandatory training.

Rotas showed staffing levels were consistently maintained, and both relatives and staff told us there were sufficient numbers of staff available to meet people’s needs. One relative told us, “I get on well with the staff. There always seems enough of them. My family member receives 2:1 staff support. I have never seen any problems.” Staff also described staffing as stable, with one member saying, “There is enough staff, there is a really good staff team here. If someone is ill or on annual leave, other staff can come in to cover.”

However, training records showed gaps, including staff who had not yet completed the mandatory Oliver McGowan tier 2 training on learning disability and autism. While staff were encouraged to complete a broad range of training courses, these gaps meant not all staff had the knowledge required to support autistic people and people with a learning disability in line with current national expectations. The Oliver McGowan Mandatory Training on Learning Disability and Autism is designed to ensure the health and social care workforce has the skills, confidence and understanding needed to provide safe, person‑centred and informed care.

The provider explained they had experienced difficulties sourcing suitable Oliver McGowan tier 2 training. They had recently appointed an Onboarding and Service Quality Support Manager in January 2026 to improve training oversight and ensure staff development needs were addressed. All staff had completed induction training, and the provider shared an action plan which set clear timescales for ensuring all staff would become fully up to date.

Staff were recruited safely. Recruitment files showed all pre-employment checks had been made to ensure only staff who were suitable to work with people were employed.

The provider assessed and managed the risk of infection effectively. Systems were in place to detect and control infection risks, and the provider shared concerns promptly with appropriate agencies when required. Staff had access to personal protective equipment (PPE) when needed. PPE includes items such as gloves, masks and aprons, and is used to help prevent the spread of infection and keep people and staff safe.

Relatives told us the home was clean and well maintained. Staff also confirmed they were supported in their cleaning duties. One staff member said, “Cleanliness at Ellis House is top notch. We have a dedicated cleaner who does cleaning every day as well as members of staff who support with cleaning on a regular basis.”

People were encouraged to take an active role in household tasks such as cleaning and cooking, in line with their abilities and preferences. During our visit, we observed people being supported to hoover, clear away utensils, and accompany staff to dispose of recycling. Staff spoke positively about people who enjoyed participating in these tasks, and this supported both cleanliness and independence.

Regular infection control audits were completed by members of the management team. These provided ongoing oversight and helped ensure cleaning standards were maintained.

The provider ensured people received their medicines at the correct time. However, further improvement was needed in relation to medicines storage and recording practices.

Relatives told us they had no concerns about the management of medicines. One relative told us the provider was actively working to reduce the number of medicines 1 person received, which reflected a proactive approach to reviewing treatment.

The service ensured people’s behaviour was not controlled through excessive or inappropriate use of medicines. Staff understood and applied the principles of STOMP (Stopping Over‑Medication of People with a Learning Disability, Autism or Both), and prescribers reviewed medicines in line with these principles. Regular medicines reviews took place to maintain safe and effective treatment.

People received their medicines at the correct times, and medicines were handled safely by appropriately trained staff. However, medicines were not always stored in a correctly monitored location. The medicines fridge temperature was being monitored daily; however, the provider was not recording the maximum and minimum temperatures, which is required under national guidance to ensure medicines are consistently stored within safe limits.

The provider acted promptly in response to our feedback and introduced a new system to record maximum and minimum temperatures. This was already in place by our second site visit.

Where people received ‘as and when required’ (PRN) medicines, staff were not always recording the outcome after administration. This information is important to determine whether the medicine was effective or whether further medical review was needed. The provider responded appropriately by reminding staff of the requirement and incorporating this into the medicines audit process.