Elliott Residential Care Home improved from Requires Improvement to Good overall following a focused inspection of Safe and Well-led domains, with prior regulatory breaches in medicines management, recruitment, and governance now resolved. Well-led remains Requires Improvement as care planning improvements and environmental audit processes were still being embedded at the time of inspection.
Concerns (3)
moderateCare planning: “Positive behaviour support plans required further development to ensure people received safe, effective support.”
moderateGovernance: “We found environmental audits required further development...broken wall mirror, toilet seats, dirty bath-mats and a window dressing that needed replacement. These had not been identified in audits.”
minor
Record keeping
: “care records required further development to ensure all information was included in people's care plans. Care plans were under review at the time of our inspection.”
Strengths
· Medicines management significantly improved: correct ordering, storage, administration, staff training and competency assessments all in place.
· Safe recruitment checks completed including overseas staff, DBS checks, references and employment history.
· Sufficient staffing levels with on-call procedures; reduced reliance on agency staff through overseas recruitment.
· Staff knowledgeable about people's needs, safeguarding, and MCA/DoLS principles; consent sought before providing support.
· Positive, person-centred culture with staff supporting people to achieve personal aspirations and maintain independence.
Quality-Statement breakdown (10)
safe: Assessing risk, safety monitoring and management; Using medicines safelyGood
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Continuous learning and improving careGood
Elliott Residential Care Home was rated Requires Improvement overall following a focused inspection of Safe and Well-led, with three regulatory breaches identified including warning notices for unsafe medicines management (Reg 12) and inadequate governance (Reg 17), as well as unsafe recruitment practices (Reg 19). Strengths were noted in infection control, cultural competency, staff knowledge of safeguarding, and the registered manager's responsiveness to concerns raised during the inspection.
Concerns (12)
criticalMedication management: “Medicines disposal did not follow safe processes. Medicines which were no longer in use were stored in an unlocked cupboard in an unlocked room.”
criticalMedication management: “Some nights there was no staff on shift trained to give medicines on site. One person told us, 'There is no-one to give me pain relief in the night.'”
criticalGovernance: “A lack of systems and processes to review medicines practices meant the concerns outlined in the safe section of this report had not been identified by the provider.”
criticalSafeguarding: “Appropriate legal authorisations were not always in place to deprive a person of their liberty. 2 people had no mental capacity assessments for sensor mats.”
criticalStaff training: “There were gaps in some recruitment and induction records. There was not always a full employment history recorded, application forms and interview records for all staff.”
criticalGovernance: “Medicines fridge temperatures were consistently warmer than the temperatures set out... identified over several months however, action had not been taken to address this.”
moderateMedication management: “Staff lacked guidance to direct them when 'as required' medicines should be given... This meant people may have received medicines inappropriately.”
moderateStaff competency: “Staff had not regularly received checks on their competency to give medicines. This meant the provider may not have identified staff who needed additional training.”
moderateCare planning: “One person who was diabetic did not have symptoms listed in the care plan for staff to look out for if blood sugars were raised.”
moderateRecord keeping: “Accurate and up to date records had not been kept... a sentence in their care plan stated 'To discover what events/activities [name] enjoys'.”
moderateIncident learning: “Incidents and near misses were recorded, however the registered manager had not reviewed them, or shared lessons learned.”
moderateIncident learning: “We identified 5 incident forms, some of which were 5 months old, which had not been reviewed by the registered manager or their deputy.”
Strengths
· Staff had training on how to recognise and report abuse and knew how to apply it
· Staff understood people's cultural needs and provided culturally appropriate care
· Staff supported people with individual communication needs consistently and effectively
· Infection prevention and control practices were assured across multiple domains
· People were supported to live culturally diverse lives including religious celebrations and diverse diets
Quality-Statement breakdown (11)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirements
This was a targeted COVID-19 infection prevention and control inspection of Elliott Residential Care Home, which was not rated overall. CQC was assured of the provider's IPC measures but identified minor improvements including an overdue IPC audit, replacement of bins with pedal bins, and additional signage.
Concerns (3)
minorInfection control: “An internal infection prevention and control (IPC) audit was overdue.”
minorInfection control: “Bins in toilets and bathrooms needed to be replaced with pedal bins, additional COVID-19 and IPC related signage was required.”
minorStaffing levels: “Agency staff were used to cover staff shortfalls.”
Strengths
· Robust visiting procedures to mitigate the risk of COVID-19, including negative tests, temperature checks, PPE and hand sanitiser.
· Staff and people using the service participating in the COVID-19 testing and vaccination programme.
· Staff had received training in infection prevention and control, including hand hygiene and safe use/disposal of PPE.
· Registered manager kept staff aware of current government guidance and sought external support when required.
· People supported to isolate during a COVID-19 outbreak with reassurance and monitoring of mental health and well-being.
Quality-Statement breakdown (2)
safe: StaffingNot rated
safe: How well are people protected by the prevention and control of infection?Not rated