Eleanor Nursing and Social Care Ltd - Oxford Office

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 good.

At this assessment the rating has changed to 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 service was in breach of legal regulation in relation to consent and people’s safe care and treatment, including medicine management.

This service scored 47 (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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Measures put in place following the death of a service user as a result of complications of their medical condition were not sufficient to prevent a reoccurrence. For some people, those risks were not identified and mitigated and for others the medical care plan put in place did not outline the risks or signs and symptoms of a deterioration in their medical condition that staff needed to be aware of and respond to. This placed them at risk of injury or death and meant learning from the previous incident was not embedded in practice. The provider assured us an information sheet was available in people’s properties to alert staff to the action to take in the event of a medical emergency related to people’s health conditions. The provider took immediate action to update the care plans we had identified with risk assessments in relation to people’s medical conditions.

The provider worked well with people and healthcare partners to establish and maintain safe systems of care. They aimed to promote continuity of care including when people moved between different services.

The service supported people on reablement packages of care which required them to be responsive to requests for assessments, to enable people to be discharged from hospital in a timely manner. They worked with other health professionals such as the GP, Occupational Therapists and Physiotherapists to promote a safe transition from hospital to home, within a tight timeframe.

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.

Staff were trained in safeguarding. However, they and the management team failed to recognise an incident of potential neglect which meant that training was not effective in safeguarding people. For example, we saw a person’s front door was not locking and left insecure. This placed the person who was deemed at risk of leaving their home unnoticed at risk of harm from others and their property left insecure posed the additional risks of unauthorised entry, burglary and potential danger to the person. This was not reported to the Local Authority Safeguarding Team to protect the person from harm and abuse. The registered manager assured us the next of kin was informed, as was the organisation responsible for the housing. However, they were not notified until 5 days after it was first recorded in the person’s daily records that the door was not locking which did not safeguard the person.

Staff were trained in the Mental Capacity Act 2005. However, they failed to complete best interest decision meeting records or liaise with the Local Authority for mental capacity assessments and best Interest decisions to be completed for people who lacked capacity on their care. As a result, the service was not aware if applications had been made to the Court of Protection for people deprived of their liberty and who lacked capacity on their care and treatment, such as locked front doors, live in carers and medicine administration.

The provider did not work 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.

Risks to people in relation to falls, medical conditions and tissue viability were not assessed.For people with diabetes, the signs and symptoms of hypoglycaemia (Low blood sugars) and hyperglycaemic (High blood sugars) were not referred to in their care plan to ensure staff recognised those and responded appropriately and in a timely manner. For a person with epilepsy, their seizure type was not outlined with no guidance provided to staff on what to do if the person was observed to be having a seizure during a care call. The provider assured us information sheets on medical conditions were in people’s properties to inform staff of the action to take. This was not reflected in care plans viewed.

Tissue viability risks were not mitigated. In people’s records we saw they were identified as a high risk of pressure wounds. There were no actions recorded to mitigate the risk. The task planner in people’s records indicated staff were to check pressure areas. However, in daily care records viewed we saw this was not consistently recorded as checked and if barrier creams were applied if prescribed. In a person’s record we saw their pressure areas deteriorated. However, this was not acted on, such as contacting the GP to prescribe barrier cream to prevent further deterioration.

Risks associated with prescribed medicines such as anti-coagulants (Blood thinners) and falls were not identified and mitigated. In 2 people’s records we saw they were identified as a high falls risk and prescribed anti-coagulants. 1 of those people had a fall on the 8 February 2025. They had a further fall on the 21 March 2025 which resulted in an ambulance being called and the person taken to hospital. Neither of those falls triggered the need for a falls risk assessment and at the time of this inspection the falls risk assessment and a risk assessment for being on a blood thinner which increased the risk of bleeding was still not in place for that person.

Other risks such as risks relating to catheter care and dehydration were not identified and mitigated. A person’s care plan made no reference to a catheter being in place with no guidance for staff on its care and what to do if the catheter was not flowing or when to contact health professionals. The person was on a fluid chart with no target amount of fluids evident to guide carers during their visits. As a result, we saw there was inconsistences in the fluid recorded. For example, daily fluid intake recorded varied from 890 mls to 1380 mls.

We saw in people’s records staff were not always observant to changes in people’s health to ensure medical intervention was sought, when people were displaying possible symptoms of a urine infection such as confusion, feeling cold and shivery and urine looking concentrated. This placed them at risk of deterioration in their health and well-being.

In response to our feedback the provider took immediate action and commenced a review of care planning and risk documentation to support greater clarity and consistency. They confirmed they were working with the support team for the electronic system used by the agency to identify ways the system could effectively support those improvements to include key clinical information.

The provider did not 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.

Moving and handling risk assessments were completed. However, we saw in a person’s file that the moving and handling equipment referred to in their moving and handling assessment was not what was being recorded in the daily care records. This had the potential to place the person at risk of injury.

The provider’s pre assessment policy indicates that personal emergency evacuation plan should be put in place. In the files viewed we saw environmental assessments were completed but none of the files viewed included a personal emergency evacuation plan,including for people who were unable to access the door. For 1 person whose care plan described them as immobile, mobility limited and also referred to as restricted, their escape plan was through the kitchen to the back door. There was no guidance provided on how they would be supported to escape through the kitchen based on their moving and handling assessment which indicated moving and handling equipment was required for transfers and there was no wheelchair available. The registered manager assured us a wheelchair was available at the property and updated the environmental risk assessment to reflect that.

Whilst staff were supported in their roles the provider did not always make sure staff were skilled and trained for their roles.

Staff told us they felt trained and supported in their roles. However, we found staff were carrying out assessments, completing risk assessments, supervisions of staff and spot checks without evidence of them being assessed and competent in those roles.

The provider audits had not identified that staff were not suitably trained in line with their policies and they had not established if other training was embedded in practice.

Staff were trained in the Mental Capacity Act (MCA) 2005. However, in people’s records viewed we saw staff were not working to the principles of the MCA which meant training was not embedded in practice.

The providers induction and onboarding policy states, ‘a carer competency assessment record to help monitor progression and competency of carers completing the care certificate induction should be completed by the assessor before signing off completion of the care certificate’. Care certificate induction was not recorded on the training matrix to indicate which staff had completed the care certificate induction. The registered manager told us there are no competency assessments and sign off of the care certificate induction and it was not identified which staff were trained to assess care certificate competencies, which was not in line with the providers policy.

Observations and competency assessments were completed for new staff although the timings of those varied. Spot checks and observations of staff on care calls were being carried out.

The rotas viewed showed some care calls were late, however the provider assured us this was because some people on reablement packages are not given a timeframe for when the call would take place. People who required 2 staff for calls were provided with them.

Staff confirmed the required call and staff numbers were provided to people and travel time was included. Some staff told us they were not consistently assigned the same people to promote continuity of care. They told us this creates more challenges for staff in relation to trying to find the time to read up on the person and find new locations.

Recruitment practices were safe, and the required checks were completed prior to staff commencing work at the service.

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.

The service had an infection control policy in place. Staff were provided with infection control training. They assured us they were provided with sufficient personal protective equipment.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences in line with best practice and the providers policy on medicine administration.

We found inconsistencies in the way topical creams were signed for. On occasions topical creams were signed on the medicine administration record (MAR) or referred to as being applied inconsistently in people’s daily care records. In 1 person’s MAR it was recorded they were prescribed [a specific cream] as required (PRN). Their care plan made no reference to it. In the daily records it was recorded creams were applied daily. However, on the February 2025 MAR the [specific cream] was only recorded as administered on 3 occasions and once on the March 2025 MAR.

The providers medicine management policy indicated a PRN protocol was required for PRN meds. None were seen in medicine records viewed. For people on ‘as required’ medicines such as barrier creams and pain relief there were no protocols provided.

In response to our feedback the provider agreed to carry out a full review of medicine practices.