Elstow Manor

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 changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 robust arrangements in place to ensure learning always occurred following incidents and accidents. Where incidents had occurred, we found these were documented, reviewed and acted on by leaders. There was evidence and staff told us ‘Lessons learnt’ were regularly discussed as a staff team. For example, following a staff member making a medicines error, there was documented reflected practice from the staff member, they had been supported by leaders to identify lessons learnt or further training needs, lessons learnt were communicated to the staff team and the person and their relatives were written to and received an apology from the provider. Reflecting on incidents, the registered manager told us, “It’s about how we learn, how we escalate and the actions we take following.” A relative said, “I never think that [Relative] is unsafe. If [Relative] has a fall [Relative] is attended to immediately and sometimes sent to the hospital.”

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.

There were robust procedures for assessing people’s needs before people started using the service. Leaders had a clear understanding of the people’s needs they could and could not meet, ensuring people could experience positive outcomes. Where people had more complex care and support needs, there were systems in place for admissions to be agreed upon and reviewed by senior leaders to ensure people’s needs and expectations could be safely met. This promoted people receiving safe support throughout their care journeys. A person said, “I am very satisfied with the choice I made to move here, the premise is first-class, high-quality set up, facilities are really good. It’s also handy for my family who live not far. I often say to myself that this was a wise decision.”

A staff member told us when new people moved into Elstow Manor, “During handover they will tell us about the person and their care plans, and we will also read their plans. If I am unclear, I will speak with the nurses or read care plans to know people well.”

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.

Whenever the service reported a safeguarding concern, the provider's internal systems meant senior leaders were notified and able to review and contribute to actions to mitigate future risks. This also formed part of the provider's systems to learn lessons, update care plans and communicate this to the staff team to reduce the risk of recurrences. Staff had received safeguarding training and knew who to report concerns to externally if needed .

People and relatives, we spoke with did not have any safeguarding concerns. A relative said, “I think they watch over them and if anything goes wrong, they will put things in place to remedy this.” A person said, “I really feel worry-free about my life and that is great relief at my age.”

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. Risk assessments and care plans were in place, specifically addressing risks people could experience, including health risks. For example, where a person was known to experience disorientation and was not always able to use their call bell, their care plans guided staff to confirm their whereabouts and well-being regularly. People’s needs in relation to assistive technology safety equipment had been assessed, and we observed people had safety equipment such as sensor mats and safety pendants if they needed them. A person said, “I have 3 alarms, 1 is always around my wrist, 1 is in the bathroom, and 1 is above my head. They were tested yesterday and working.”

The provider was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care.
The provider maintained a high-quality, well-presented environment. A relative said, “The facilities are very nice, the rooms are very nice, and I am satisfied.” Lights in people’s bathrooms were sensor operated. Signage and landmarks within the home had been updated to make it more accessible and familiar to people living with dementia who have care and support needs around how they orientate themselves. Equipment such as lifts, hoists and those related to fire and gas safety had been inspected in line with requirements. People’s equipment, such as their beds, call bell systems, wheelchairs and walking aids, were assessed for safety monthly.

The provider ensured there were enough to care for and support people safely. Overall , the people, relatives and staff we spoke with felt there were enough staff, but it was felt sometimes staff could take longer to respond at times when staff were unforeseeably absent at short notice. Records showed the service had regularly been staffed at or above the providers assessed safe staffing numbers. We reviewed staff recruitments files and found staff were recruited safely.

Staff had received training relevant to their roles and received regular supervision and development opportunities. The provider had invested in staff becoming trainers in areas such as moving and handling, basic life support and fire wardens. This promoted staff members continued professional development and meant other staff could receive training in these areas when required. A staff member said, “The quality of the training is good. It’s specific to what you need in a care home.” Another staff member reflecting on their induction told us, “Induction was ok. It didn’t fully prepare me for everything. Sometimes what you learn on the computer is different to what you see face to face, but the staff were supportive, and you can bring up any concerns with anyone, and they will help.”
 

The provider assessed and managed the risk of infection. They quickly detected and controlled the risk of it spreading and always shared concerns with appropriate agencies promptly. We observed the environment was clean and free from malodour. There were systems in place to ensure visitors were not experiencing ill health that could make people unwell when they entered the building. A staff member said, "I think the place is clean. The good thing here is the cleaners make sure the home is clean." Regular infection prevention and control audits took place. There were systems in place for the service to communicate infection outbreaks to the provider's senior leadership team. This provided oversight of actions taken and how infection-related risks were managed. A relative said, “Elstow Manor is clean, comfortable, well resourced, caring with the interests of service users at their core .”

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.

We signposted the service to information that could be added to people’s care plans to include more person-centred information as to what would indicate people needed medicines prescribed to be used on an as-required basis. The provider acted on this feedback straight away and staff felt confident enough to ask inspectors to review improvements they made.

Where people needed to receive their medicines covertly, the service involved people, their relatives and relevant medical professionals. We observed that individuals who had been assessed as needing to take their medicines covertly were still offered their medicines overtly by staff, who explained the prescribed purposes of these medicines before considering whether covert administration was in the person's best interest.

People's independence was promoted, and staff only gave people the support that they needed. For example, the service had assessed a person could take their medicines independently, and so they did so, but with the agreement of the person, staff undertook regular stock checks with them. A person said, I have absolute trust in the Clinical Lead. [Clinical Lead] started a year ago and without me saying much to [Clinical Lead], without any request they looked into all my meds. [Clinical Lead] suggested we go back to the GP and change it. [Clinical Lead] helped me with everything.” The person explained to us that their health condition had improved following the clinical lead arranging for medicines to be reviewed with the GP.

Medicines were stored safely. This included safe systems around controlled drugs, storage and ensuring medicines were labelled upon opening. Regular detailed medicines audits took place both by the clinical lead at the home and the provider's quality assurance team. Where improvement areas were identified, we saw actions were planned and completed around this. Staff had been trained to administer people’s medicines and had been assessed for competency to do so.

Reflecting on the improvements the service has made with medicines, a staff member said, "At the last inspection, there were so many discrepancies, now it's much better. We are managing it better now."