Eachstep Lockwood 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 remained requires improvement. This meant some improvements were needed to make sure that all aspects of people’s safety were considered and action taken as needed. Some environmental improvements were identified and staff needed to ensure safeguarding issues were identified and reported in a timely way.

The service was no longer in breach of legal regulation in relation to environmental risks or safe management of medicines.

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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

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’s needs were assessed prior to them being offered a place at the service. One person and their visitor told us this process had been very thorough with managers getting to know the person and obtaining information from previous care providers and involved professionals.

Assessment detail was used to develop initial care plans.

Staff told us how they were working with a person living at the home for short term care to prepare them for going home.

The provider had not always shared concerns quickly and appropriately.

An incident had occurred which had made a person feel unsafe. This had been recorded and discussed with the people involved. Staff had been made aware of the incident and knew what to do to minimise the risk of the incident being repeated. However, a safeguarding referral had not been made. This was done following our visit.

Staff said they would not hesitate to report any concerns they had about people’s safety and a senior care worker told us they knew how to make a safeguarding referral. Staff talked about environmental safety as well as physical and psychological safety.

People told us they were confident in staff to keep them safe.

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

Risks to people’s health and safety were assessed using a number of recognised risk assessments such as Waterlow for skin integrity and MUST for nutritional needs. The provider encouraged positive risk taking where this was appropriate. An example of this was a person who was at risk of falls but understood this risk and had the capacity to make decisions about their support. It was recorded that the person had said they did not want to have a sensor mat or other falls alert system in place, although the person had not signed their risk assessment to evidence their involvement.

The provider did not always make sure equipment, facilities and technology supported the delivery of safe care.

On our first day of assessment, we talked with the maintenance person. We became aware of an issue where some key coded fire doors were not automatically releasing when the fire alarm sounded. This meant the door codes would be needed to open the doors in the event of a fire. We were informed all staff had a slip of paper with the key codes on them to use in the event of this happening. However, 2 of the 5 staff on duty did not have these key codes with them. We raised this immediately with the management team who took immediate action and the issue was resolved on the same day.

The provider was opening 6 bedrooms at a time as they were refurbished and made safe and comfortable for people to move into. At the time of the assessment only 6 bedrooms were available. We saw safe bathing or showering facilities were not available on the same floor as the occupied bedrooms. Although a shower was on that floor, the fitting of the shower cubicle made it unsafe to use. This had been recognised by the management team who had made the decision not to use it. The shower room people were using required redecoration due to paint peeling off the walls and the shower curtains in place were ill fitting and falling down. The bath on that floor had been assessed as unsafe to use.

Following our visit the provider confirmed the shower room had been re-decorated, and a new bath was ordered.

Personal emergency evacuation plans (PEEPs) were in place and contained some good detail. However, one did not include the information needed about the person’s mobility needs or that they would require a wheelchair for safe evacuation.

There was a business continuity plan in place to ensure continuity of service in the event of an emergency.

The management team were working with the maintenance person to identify and quickly address environmental issues.

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.

At the time of our visit there were only 2 people living at the service. The home was staffed 24 hours a day by a senior carer and a care assistant with management, administration and maintenance staff adding to the staff team during the week. Catering staff were in the service 7 days a week. Due to the low occupancy, care staff completed cleaning and laundry tasks.

Staff told us the current staffing levels were appropriate and the people living at the service felt staff were available to them as they needed. A system to assess staffing levels in line with the dependencies of people living at the home was used.

Processes were followed to ensure safe, effective recruitment and systems were in place to make sure staff received the induction, training and support they needed.

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.

A recent infection prevention and control inspection by the local authority highlighted a number of areas requiring attention and action to make sure risks of infection were minimised. An action plan had been developed to address the issues identified and many had been resolved. However, on the first day of assessment we found some toilets and bathrooms did not have any handwash available. We also found an unclean toilet and some mops were stored with mop heads in water.

The maintenance person told us they had ordered and were fitting new hand wash dispensers that day and this was done, however interim arrangements had not been put in place to make sure effective hand hygiene could be completed.

All of the above was addressed effectively on the day.

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.

Safe systems were in place for storing, recording and administration of medicines.

Where medicines needed to be administered at a particular time, for example, early morning, records showed this was done.

When medicines had been administered on an ‘as required’ (PRN) basis, a record was made of why it had been given and if it had been effective. Clear instructions were in place to advise staff about how some medicines might interact with each other. For example, instruction was in place for staff to make sure they administered a PRN medicine to prevent possible gastric irritation prior to administering a PRN pain relieving medicine.

A detailed care plan was in place for the possible effects of a blood thinning medicine which gave staff clear information of what to observe for and when to seek medical advice.

A medication review had been requested and completed when one person’s prescribed medicine was unavailable at all pharmacies and was out of stock nationally. However, this change had not been reflected in the person’s medicine care plan.

A senior member of care staff had the role of ‘medication champion’ and they had received training to support them in this role. Systems were in place for checking the competencies of staff dealing with medicines.

Where a medication error had occurred, this had been reported, investigated and learned from.