Southport care home rated ‘Inadequate’ after safety failings leading to one resident falling 26 times

The Care Quality Commission (CQC) inspectors reported filthy pillows and bedding and a strong smell of urine throughout the building. The report also highlighted Ellerslie Court’s prolonged ‘understaffing’ meaning people were receiving inappropriate and unsafe care and were at risk of harm.

An update has since been provided by Sefton Council, which confirmed ‘extensive changes’ had been implemented since July. Sefton councillors convened at Southport town hall on September 2 for the Adult Social Care and Health scrutiny committee and were presented with a number of council reports into the performance of care services in the borough.

One of the agenda items was an update from the council’s Quality & Compliance Team’s assessment of care and support provision. Sefton’s Adult Social Care has a quality assurance (QA) team is a separate organisation to the Care Quality Commission and often provides more regular reviews of care homes in the local authority area.

It is not unusual for care homes to wait several years in-between CQC inspections. The council report said the QA team works to identify providers needing support and aims to ensure ‘quality in all aspects of service delivery’ through partnerships with social workers, therapists, and health partners.

There are 116 care homes in Sefton, with 112 of these having a verified CQC inspection rating. Only one care home in Sefton currently has an ‘inadequate’ rating, which was the result of a CQC inspection conducted at Ellerslie Court, Southport, in February.

The committee was presented with a report by Sefton Council’s assistant director commissioning and transformation in adult services, Hannah Soetendal, who highlighted two anonymised examples of ‘pro-active work and successful outcomes’ after QA visits to care homes in North Sefton and South Sefton.

The report referred to the one anonymised provider as ‘Care Home B’, but did indicate the facility is based in North Sefton, has 15 beds and was subject to a CQC inspection in February – resulting in an ‘Inadequate’ rating. The LDRS understands ‘Care Home B’ refers to Ellerslie Court in Southport.

A CQC report published in July – after an inspection in February – found residents at the home were unsafe and at risk of harm. As a result of that report, Ellerslie Court was plunged into special measures as the CQC took urgent action to protect those inside.

One resident was found to have fallen 26 times, five of which had resulted in significant injuries. Leaders hadn’t informed the CQC or the local safeguarding team about these incidents, and they hadn’t completed risk assessments to reduce the chances of it happening again.

Leaders also failed to ensure the home was clean and free from infection. Inspectors saw filthy pillows and bedding and there was a strong smell of urine throughout the building.

Karen Knapton, CQC deputy director of operations in the North West, said: “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.

“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.”

According to Ms Soetendal’s report, Sefton Council’s QA team have been working with Ellerslie Court and said extensive changes ‘in management and oversight of systems have now been instigated which was absent previously’.

The report added: “Quality Assurance Officers worked with the Provider who was responsive and worked with Sefton to identify, and put in place critical actions, and help to create a safer, more sustainable service. The Quality Assurance Team initially worked with the service in a recovery action plan phase conducting weekly visits initially gradually reducing these to bi-weekly then three weekly.

“Currently the service is mid-way through a PAMMs audit and we hope that the improvements and on-going plans will evidence the hard work the team at Ellerslie have completed since the very poor findings through CQC in February and March of this year.”