A care home in Merseyside where residents were discovered to be unsafe and at risk has been put into special measures as the Care Quality Commission (CQC) takes immediate action to safeguard those within. Ellerslie Court in Southport has been deemed inadequate by the CQC following an inspection in February and March. The inspectors identified fire hazards at the facility and noted that staff did not consistently manage or administer medications safely.
They reported that the home’s leaders had failed to report certain incidents to the appropriate authorities and had not conducted investigations to ensure resident safety. One resident was found to have suffered 26 falls, five of which resulted in significant injuries.
The CQC and local safeguarding team were not informed about these incidents by the home’s leaders, who also neglected to carry out risk assessments to prevent further occurrences. The leadership also failed to maintain a clean and infection-free environment.
Inspectors observed dirty pillows and bedding, and a strong odour of urine permeated the building. The inspection at Ellerslie Court, operated by Lotus Care and providing care for adults of all ages, including those with dementia, was carried out in response to identified risks that could potentially harm residents.
The home received an inadequate rating in the categories of safety, leadership, and effectiveness, reports the Liverpool Echo. Violations were found in relation to safe care and treatment, person-centred care, consent, staffing, and the management of the home.
The CQC has now put the service into special measures, which involves stringent monitoring to ensure safety while improvements are made. Special measures also provide a clear timeline for services to understand when improvements must be made and what action the CQC will take if this doesn’t occur.
Inspectors criticised the care provider for not fostering “did not have a proactive and positive culture of safety based on openness and honesty.” They added: “They did not listen to concerns about safety and did not investigate or report safety events.”
For instance, the CQC noted an inappropriate use of a smoking area outside a fire exit door. During both days of their site visits, they observed the same fire door being kept open and used as a smoking area, setting off the smoke alarm.
The report further stated: “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.” Karen Knapton, CQC deputy director of operations in the north-west, expressed her disappointment: “When we inspected Ellerslie Court, it was disappointing to see such a deterioration in the quality of care being provided.
“Poor leadership had led to issues including prolonged understaffing meaning people were receiving inappropriate and unsafe care and causing low staff morale.” The report highlighted severe understaffing issues, with one alarming statement reading: “Due to this understaffing, people were regularly and repeatedly having falls.
“For example, one person had fallen 26 times at the home, five of which had resulted in significant injuries. Leaders hadn’t informed CQC or the local safeguarding team about these incidents, and they hadn’t completed risk assessments to reduce the chances of it happening again.
“This volume of falls indicates staff didn’t have enough time to help people at risk of falls move around the home.” It also detailed neglect in care for those prone to skin conditions: “Similarly, staff didn’t have time to support people at risk of skin tears and pressure sores.
“One person’s medical notes stated they needed repositioning regularly, but we saw they’d been sat in a wheelchair for five hours which placed them at risk of their skin condition worsening.” The situation fostered a negative environment as the report continued: “This regular understaffing led to a poor culture and people’s needs not being met due to an over-reliance on agency staff who didn’t know people well.
“Interactions between staff and residents weren’t warm or friendly and were often task-focused placing people at risk of loneliness.” Furthermore, the use of untrained personnel compromised safety: “Additionally, agency staff were sometimes given inductions by unqualified staff which led to people receiving unsafe care.
“For example, eight people hadn’t received their prescribed medication placing them at risk of harm. We have told leaders where we expect to see rapid, and continued improvements and will continue to monitor the home closely to keep people safe while that happens.
“We will return to check on their progress and won’t hesitate to use our regulatory powers further if people still aren’t receiving the care they have a right to expect.”
Lotus Care was approached for a response.