Ellacombe

Updated 20 October 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 2 inspectors, and 1 Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Ellacombe is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Ellacombe is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We reviewed information we held about the service, and liaised with health and social care professionals who work closely with the service. The information gathered formed part of our inspection planning.

During the inspection

We spoke with 13 people living at the service and observed care and support provided in communal areas. We spoke with 8 people’s relatives or friends. We spoke with the registered manager, 2 deputy managers, 4 care staff, a senior member of staff, the regional manager, an activity coordinator, a chef, 6 ancillary staff and a housekeeper.

We looked at 4 people’s care and support records and 3 people’s medicine records and 6 people’s topical medicine charts. We also reviewed 4 staff files as well as records relating to the management of the service, recruitment, policies, training records and systems for monitoring quality.

We continued to seek clarification from the provider to validate evidence found.

Updated 20 October 2023

About the service

Ellacombe is a residential care home providing care and support to up to 45 people. The service supported people living with dementia. At the time of our inspection there were 34 people using the service.

People’s experience of using this service and what we found

Improvements were required to protect the condition of people’s skin to reduce the risk of developing pressure sores. Changes to the recording of when checks of people’s skin took place needed to be improved.

Where people were meant to have additional calories added to their diets to support weight management, records did not show this was consistently being provided. This was of particular concern where their daily food records showed they had experienced an overall poor intake.

If people smoked, particularly if using flammable creams on their skin, management plans in place to protect them from harm were found not to be consistently followed.

Some people were known to be at risk of accessing other people’s bedrooms, going through drawers and potentially taking items without staff support and supervision. We found drawers containing craft and gardening items, as well as personal cigarette lighters and tobacco, alcohol and items of food that was not found to be stored securely. The assessment of such risks was required to maintain people’s individual safety, particular for people living with dementia.

Some improvements to the management of people’s medicines were required, in relation to the consistent application of creams. Also, in relation to the guidance in place for staff to follow where people received their medicines covertly (hidden in food or drink).

Whilst we identified some areas of improvement still required at the service, we also identified areas of development and changes made as an outcome of findings from our last inspection. Overall, we found a clear intent by the registered manager to support ongoing improvement at the service.

There were sufficient numbers of suitably trained staff available to meet people’s needs. We observed kind and meaningful interactions between people and staff during our inspection. We received mainly positive feedback from people living at the service and their relatives.

We found the registered manager and staff team responsive to our feedback and were keen to make improvements and changes to ensure people received good standards of care. Staff proactively fund raised to support inhouse and external activities, and wanted to ensure people’s wellbeing remained a priority of their care.

Staff morale was observed to be good, and we received positive feedback about working at the service. Staff showed compassion and changes in leadership at the service since our last inspection were supporting a changing culture within the staff team.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 01 February 2020).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of regulations.

Why we inspected

This inspection was prompted by a review of the information we held about this service and in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of relating to the provision of safe care. This inspection examined those risks.

As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service remains requires improvement based on the findings of this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ellacombe on our website at www.cqc.org.uk.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.