Eastside House

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 remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was previously in breach of the legal regulation in relation to safe care and treatment. Sufficient improvements were not found during this assessment, and the provider remained in breach of this regulation.

This service scored 62 (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.

The provider had effective incident reporting and learning systems. The team discussed incidents during handovers and staff meetings, with immediate escalation where required (including group communications for urgent issues). The registered manager feed this learning into updated risk assessments and people’s care plans.

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.

People were supported to remain safe because staff understood risks to people and monitored them regularly. Staff shared important information with each other so that everyone supporting a person knew what to do to keep them safe.

Staff worked well with other professionals, such as GPs and social workers, to make sure people’s health needs were followed up and that nothing important was missed.

When people moved between services, staff planned these moves carefully. They checked essential information, such as medication and support needs, before a person arrived or left. A staff member told us, “When people move in, we get everything in detail, including preferences.” This matched what we saw in admission checklists and handover notes, which included people’s medical history, communication needs and personal routines.

These checks and handovers helped make sure people experienced a safe and well‑coordinated transition.

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 safeguarding procedures and knew what to report and to whom, and they were confident appropriate action would be taken. People appeared safe, and a relative we spoke to confirmed their family member was kept safe in the service. Staff reported they had not needed to raise safeguarding concerns. A staff member we spoke to said, “I will inform management and senior staff of any issues or concerns.”

We viewed records which confirmed the provider maintained and reviewed safeguarding policies and procedures.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff involved people and relatives in risk assessments, although these were not always comprehensive or consistently completed.

Records showed the provider completed assessments covering areas such as health conditions, behaviour support and mental health. Key workers worked alongside 2 or 3 other staff who knew each person well, which helped keep support consistent.

This meant people received care from staff who understood their needs, responded quickly when risks changed and helped prevent avoidable incidents.

Records showed the registered manager analysed incident trends and acted on learning.

Staff we spoke to said they support people’s decisions and understand the concept of unwise decisions and completed reviews regularly.

However, 2 people were prescribed emollient creams for which risk assessments were not in place. Whilst staff we spoke to showed awareness of the associated risks, this documentation gap was an area for improvement.

The provider did not always detect and control potential risks in the care environment. They did not consistently ensure that equipment, facilities and systems supported the delivery of safe care.

There was a risk that people would not be safe in the event of an evacuation due to fire. During our assessment we checked the fire grab bag and found the list inside it was out of date; it included people who no longer lived at the service. This could cause confusion in an emergency situation, delay the fire service response and place people at increased risk. Corridors were generally uncluttered, however we found a mattress stored in a first floor corridor along a fire escape route. This presented a potential hazard to people during an evacuation.

Staff told us they received fire safety training and took part in regular fire drills and evacuation practice. Records reviewed showed that fire drills had taken place on multiple occasions, included different evacuation scenarios, and the use of evacuation equipment. The registered manager recorded attendance of staff, and contractors completed routine checks of the fire alarm and detection systems.

However, fire drill records did not include an evaluation of the drills or demonstrate that the provider reviewed how effectively evacuations were carried out. Records did not identify any learning, actions for improvement, or how the provider assured themselves that evacuation arrangements were safe and effective for all people using the service. This limited the provider’s oversight and assurance that fire safety arrangements were robust.

People who could use them had access to call bells to alert staff if they needed care or support.

During the assessment visit, the registered manager and staff took immediate action to address the issues we identified. They removed the mattress in the corridor and updated the name list in the grab bag.
 

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.

The provider maintained safe staffing levels, and staff responded promptly to people’s needs, including call bells. Records confirmed a stable team with routine supervision, including additional oversight for staff on sponsorship arrangements. Meeting minutes confirmed that the registered manager held annual and weekly staff meetings that reinforced professional standards and decision‑making responsibilities. The registered manager described the team as hard‑working and engaged.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff were aware of infection control procedures. Staff used appropriate PPE [personal protective equipment] where required and had enough stock. Many of the staff had worked through the Covid-19 pandemic 5 years before so they knew how to keep people safe in the event of an outbreak. Staff followed an established cleaning schedule, and the environment looked generally clean.

The provider did not ensure that medicines and treatments were consistently safe or met people’s needs, capacities and preferences. Staff used PRN and psychotropic medicines without sufficient guidance to support safe, proportionate and person‑centred use. Where PRN medicines were given, staff did not consistently record the impact, duration or any adverse effects. This limited their ability to evaluate whether medicines remained effective, necessary or safe, particularly for people who were less able to communicate how they felt. Staff administered psychotropic medicines, including diazepam and haloperidol, without adequate oversight. In some cases, records did not clearly explain why medicines were started, how staff should monitor their effect, or when they should be reviewed or discontinued. Although staff sometimes attempted non medicines approaches, these were not consistently embedded as part of a clear, structured decision making process prior to the use of PRN medicines. This meant there was a risk that restrictive medicines could be used when alternative approaches may have been effective. While routine non PRN medicines were generally managed appropriately, including ordering, storage and administration, these strengths did not mitigate the risks arising from poor oversight of PRN and psychotropic medicines. Following the assessment, the provider shared examples of PRN documentation. However, this did not demonstrate that guidance was consistently accessible, embedded in practice, or effective at the time of assessment.