Archived: Eboracum 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 changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, the management of risk and the ways people’s medicines were managed at the service.

This service scored 34 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

People and relatives expressed mixed views about the quality of care. Our assessment found elements of care did not meet the expected standards.

The management team told us they were committed to learning and improvement of the service. However, we found several concerns that had not been identified as part of the quality assurance process, which meant staff were still not consistently following processes and guidance. This put people at risk of harm.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Staff and managers told us information from people’s care plans and medication administration records were collated and shared at the point a person needed to move services, for example to visit hospital. However, during the inspection issues were identified with the level of accurate and up to date information in people’s written records. This placed people at potential risk of harm. The processes in place for ensuring that information was up to date, accurate and consistent had not identified these issues. We received concerns from visiting professionals that safe systems were not in place to ensure people’s needs were met or promoted safety.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

People who lived in the home and those being cared for in their own homes told us they felt safe in the care of the staff. One person said, "Yes, I'm safe."

Staff we spoke with told us they had received ‘safeguarding adults’ training and the staff records we reviewed confirmed this. Staff were able to describe different types of abuse and where they would report any suspicions of abuse. The provider had policies and procedures for safeguarding vulnerable adults and the manager was familiar with how to report any safeguarding concerns.

However, we were not fully assured staff would recognise and report safeguarding concerns. For example, we found multiple concerns in relation to the management of medicines. Due to concerns found during our visit we asked the provider to submit to a referral the local safeguarding authority.

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

People's care plans were not always up to date. Inconsistent information was viewed which related to the monitoring of people’s health and care needs. For example, a person’s care plan stated they were at high risk of falls, however, the falls risk assessment showed the falls as a severe risk. Moving and handling risk assessments were basic, not person centred and did not detail actions staff should take should there be a fall or accident.

People who were at risk due to diabetes did not have clear guidance in place to mitigate any potential risk. For example, care plans did not detail what action staff should take or how to safely monitor a person's blood glucose range. Therefore, staff were not provided with person specific information on how to recognise and manage possible risks with diabetes or how to escalate concerns. Where a person needed a catheter, there was no risk assessment in place.

People at risk of falls, or who had recent falls, were not consistently reassessed. We could not be assured staff were following people's updated care plans or were aware of any changes to their support needs.

Some staff knew people and their needs, but this was not the case for all staff. Records indicated people had not always received the care they needed with regard, for example, to repositioning. One member of staff said they checked the mattress settings to ensure they were appropriate for the person using them. However, these were not recorded. This meant we could not be assured they had been set to the correct weight.

Governance and audit process at the service had failed to identify deficiencies within people’s care plans and risk assessments.

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

We identified some environmental shortfalls during the inspection including staff not having access to appropriate equipment, doors not being locked to areas that were unsafe and many areas in the service were worn and in a general state of disrepair. Several areas of the home appeared tired and required refurbishment and redecoration; chipped paintwork, walls and door frames with holes needed refilling and repainting, and ceiling tiles needed repair.

Checks were carried out to monitor the safety of domestic systems, includingwater temperatures, emergency lighting and call bell systems. However, someenvironmental risks were not managed. Staff reported that equipment, such as shower chairs and bath hoists, were either broken or not fit for purpose. For example, the shower chair was broken and staff said they had to use a jug to assist people with showering because they could not safely regulate the electric shower’s water temperature. Although no harm to individuals was identified, the inability to control water temperature increased the risk of scalding or burns.

We found fire exits and outside walkways blocked and not well maintained. This showed a failure of the provider to monitor and improve risks to people’s health and safety. These concerns were raised with the manager who assured us that immediate action would be taken to resolve these concerns.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff told us they received training and felt supported by the manager. Appropriate recruitment checks were conducted prior to staff starting work to ensure they were suitable to work with vulnerable people. Records we looked at confirmed this. There were processes in place for sharing information between staff which included a handover meeting and daily flash meetings to share information and improve practice.

We found enough staff on duty on the day of our site visit. The registered manager used a dependency tool to determine staffing levels and we saw this was followed. However, we observed staff could be task orientated with set times for specific support, rather than care being person-centred, and some people were left alone when they required support.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We completed a tour of the home with the manager and found some areas which were not well maintained and unable to be cleaned effectively. Parts of the service needed repair and re-decoration because they posed a risk to people. Cleaning of these areas would be more difficult and kitchen worksurfaces, tiles and flooring needed replacing and updating,

Staff were aware of correct policies and procedures for infection control. However, we found soap dispensers which were empty and personal protective equipment (PPE) stores for aprons and gloves required replenishing. Staff did not have easy accessibility to supplies of PPE to ensure it was used appropriately to prevent the spread of infection.

We also found additional issues which required attention, such as a prescribed cream found in a bathroom and people’s toiletries and hairbrushes found in the dining room.

The audit tool used had not identified the areas that required attention. This was discussed at our visit and some improvements were made on the day but had not been picked up as part of the provider’s quality assurance systems.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Managers told us they were aware of their medication management responsibilities and had a medication policy in place. However, systems were not in place to ensure the proper and safe management of medicines, which placed people at risk of harm.

Medicines trolleys and fridges were not always stored securely in an appropriate room. Temperature monitoring of these rooms and fridges was not documented daily as per the provider’s policy. Creams were not stored securely. This issue had not been identified by the management team and staff when completing monthly audits.

Protocols were not always in place for 'as and when required' medicines (PRN). Medication care plans were also not specific or detailed with this information. This meant staff did not have appropriate instructions and information on how and when to administer medicines prescribed to be taken as required.

Topical Medication Administration Records (TMARS) were not always completed consistently. TMARS contained gaps in recording administration. Therefore, the service could not demonstrate people received their creams as per prescriber’s instructions. This could compromise their skin integrity.

Medicine stocks did not tally with medicine administration records (MARs), which meant medicines could not always be accounted for. On the day of our inspection, previous stock levels had not been carried forward to the new cycle and we found that stocks of medicines were disorganised.

There was no evidence that a second staff member had checked the entries were correct on handwritten MARs which meant staff were not following the service's policy. This increased the risk of medicine errors.