Elton Park Care Home

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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has improved to 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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Falls and incidents were monitored and checked for any trends. Actions were taken to reduce future risks, such as the provision of equipment and referrals to external professionals.

Lessons were learned from incidents, accidents and feedback received. Information was shared with staff via staff meetings to ensure they were made aware of the lessons and requirements of their role. The manager told us they were working on improving the documentation for lessons learned.

There was a duty of candour policy and procedure in place which was understood by staff.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Information was in place when a person was admitted to hospital, to ensure important information was shared. A staff member told us how they were updating a person’s risk assessments and care plan following a recent stay in hospital to ensure the transition was smooth and the person received consistent care.

A person’s relative told us how they had supported them and their family member when they first moved into the service. They said due to the support provided their family member was settled in the service.

Where the provider felt they could not meet people’s needs, actions were taken to gain support from the placing authority to find an alternative placement. The manager shared examples where they had spoken with a person about an area they preferred to live and this was shared with other professionals. They were committed to continue to support the person until a move could be identified.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff understood their role and responsibilities relating to safeguarding and had received training and had access to the provider’s safeguarding policy and procedure.

Safeguarding referrals were raised as required. In addition, the manager worked closely with the commissioner and referred any falls and incidents to the commissioner who advised if a safeguarding referral was required when it met the local authority threshold. Actions were taken as required. However, the manager had not notified CQC of two incidents between people which had not required a safeguarding referral but were notifiable incidents. We discussed this with the manager and found it had been a misunderstanding of the requirements of the local authority and CQC. They understood and addressed this.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People’s care records included risk assessments which provided guidance for staff in how the risks were reduced. This included risks associated with mobility, nutrition and hydration, choking, skin integrity, using the stairs and smoking.

People told us they felt safe living in the service, which was confirmed by relatives. One person said, “They lock the doors at night, it is 100% safe here.” Another person said, “Last week I went into the [person] opposite to say hello and suddenly two carers came rushing is, I had put my foot on the mat on the floor, they came straight away, that made me feel easier knowing that they are on it.”

People and relatives told us the actions taken by staff when there was a risk of falls. A person told us how they had a fall and how they have been provided with equipment in their bedroom, including, “An aid on the bed to help me pull myself up, and I hold onto that,” which made them feel safer. This demonstrated the service worked with the person to reduce risks. A relative said, “They are doing pretty well, [family member] has got dementia. Mattress and pressure mat went down pretty soon after [family member] came, [they] slept on the edge of the bed so [staff] said that they put the mattress and pad down as a precaution, they lowered [family member’s] bed at the same time.”

People’s choices and decisions were valued and respected in relation to risks. The manager told us a person refused to accept the diet recommended by the speech and language team (SALT) to reduce risks of choking. Whilst their choices were respected and they were able to make an informed choice; the staff observed them when eating to reduce the risks. Where another person required a different texture diet to reduce risks, we observed this was provided.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

There were regular checks on the environment to ensure people were safe. A health and safety audit completed in July 2025 by an external contractor showed 97.76% compliance. However, on the first visit to the service, we showed the provider a blockage in the drain coming from the kitchen. The control of substances hazardous to health (COSHH) cupboard lock was loose. These were rectified immediately once we pointed it out.

There were several items, such as furniture, behind the shed. We identified the metal edging on the bottom of the stairs was bent outwards which was a risk. These had been addressed by our second visit.

Several people smoked and we could see they used this time to socialise with other people in the garden. However, the receptacle for cigarette ends in the shelter was too high for people to reach if they used a wheelchair and the people were not using the shelter. They sat at a table in the garden, where there was a plastic bucket which held some cigarette ends and there were numerous cigarette ends on the lawn, which were a fire risk if the cigarettes had not been fully doubted. When we pointed this out a new bin and sand had been ordered and by our second visit, the manager and a person who used the service had cleared up the majority of cigarette ends.

The provider told us how actions had been taken to ensure the environment was safe, this included a review of the staffing model, addressing compartmentalisation, and fireproofing the ceiling in the basement, following advice being received from fire safety professionals, this was confirmed in the facilities action plan reviewed. In addition, there were four boilers in the service, pipework was being renovated. The fire risk assessment was booked to be reviewed 28 July 2025, the provider told us they would update us with any actions identified.

A new maintenance staff member had been in post since February 2025, they were working between two of the provider’s homes. Regular checks were undertaken to ensure the environment and equipment was safe, including moving and handling equipment, fire safety, window restrictors, and electrical equipment. Fire drills were undertaken to ensure staff understood the actions required in case of a fire. Personal evacuation plans were in place which showed the support people required should the service need to be evacuated.

The provider’s contingency plan identified the systems in place in the case of an emergency such as power loss, flood and gas leak. Environmental risk assessments were in place which identified how risks were mitigated, this included the stairs.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We received mixed views from people if there were enough staff to support them. Some people told us they had to wait for assistance whilst others said the staff were available when they needed help. Two people told us they had to wait to be supported back into the service when they had been in the garden. The manager told us that staff kept going outside to check on people’s safety and when they wanted to go back into the house. This was confirmed in our observations.

The provider used a dependency tool to help calculate the numbers of staff needed. They had kept the staffing levels under review and amended them as new people moved into the service. The provider told us how the staffing levels continued to be reviewed and adapted where needed. Since our last inspection, changes in how the night shift was staffed had been implemented, with two care staff and a senior on each night. The provider told us they had a strong senior staff team.

Staff were recruited safely. Staff received training relevant to their role and received one to one supervision meetings which provided a forum to receive feedback, discuss any concerns and identify any training needs.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

People and relatives told us the service was kept clean. One person said, “They wash and hoover in here [bedroom] every day.”

During our first visit, we saw the dining room had cobwebs and the skirting boards were not clean. In addition, there were cobwebs in the hall on the ground floor and in a bathroom. Immediate action was taken when this was pointed out. The manager told us they had spoken with the provider the day before our visit to request additional domestic hours. On our second visit, the manager and provider told us the additional domestic hours were in place, we saw the service was clean.

A person’s bedroom had a screen over the patio doors, this was unclean, the manager told us a new one had been ordered. There was a malodour in a person’s bedroom. The manager told us what actions were being taken to support the person, who was reluctant to accept support, this included a visit from the continence team and liaising with commissioners. We were assured this had been identified and actions being taken to reduce risks.

Drink jugs in the dining room, were labelled to show the date to demonstrate the drinks were fresh, however, where previous stickers had been removed there remained a sticky residue where bacteria could develop, these were cleaned immediately.

There was a stock of personal protective equipment including gloves and aprons, we saw these were being used when needed by staff. Toilets and bathrooms held hand cleaner and paper towels to reduce the risks of cross contamination.

We observed part of a morning medicine round and saw the staff member cleaned their hands in between supporting each person with their medicines. Staff hand hygiene competencies were in place.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People told us they received their medicines when they were needed. A person told us how they felt the management of their medicines was safe, the staff were on time when bringing their medicines and stayed until they had seen the person taking them. A relative told us their family member had been refusing to take their medicines, “[Staff] have been encouraging [family member] and tried different things and worked out how to get [family member] to agree to take them.”

The manager told us all people had received a review of their medicines by the GP surgery staff in June 2025. We saw evidence to show the service were liaising with the GP and pharmacy when medicines were not available, this was not to the staff not ordering the medicines, but due to the availability in the community. The manager told us changes in the pharmacy used to ensure the needs of the service were being met. A staff member told us they had good relationships with the GP and pharmacy, and they worked in partnership.

Staff responsible for supporting people with their medicines were trained to do so safely and their competency was checked. The manager told us that competencies in cream administration had started.

We observed part of a morning medicine administration round; this was done safely. The staff member was knowledgeable about the requirements of their role and explained the procedures in place for the safe management of medicines. Medicines were stored safely, temperatures checked and systems in place for ordering and disposing of medicines. Where people required medicines to be administered as required (PRN) there were protocols in place, which may benefit from more detail, discussions with the staff member demonstrated their knowledge in this area which assured us risks were reduced of inappropriate administration.

Medicines administration records were completed appropriately. Audits and monitoring systems supported the management and senior team to quickly identify any discrepancies and address them.

Where people were prescribed medicines in the form of patches, records were kept to show when they had been removed and what part of the body they had been placed. However, the staff team had developed a system where codes were used, which were not easily understood until they were explained to us by the staff team, the body maps used to show where they had been placed were not always being used. At feedback we were assured by the management team the system had been reviewed to ensure the records were completed in the way they were intended and could be clearly understood by other professionals and staff.