Eastwood 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 service was in breach of legal regulation in relation to safe care and treatment and governance.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were not learnt to continually identify and embed good practice. Incidents and accidents were not reviewed and analysed in a timely manner. This meant there was a risk incidents and accidents would reoccur. For example, we found an incident where a person had fallen and suffered a significant injury requiring hospital treatment. The registered manager had not investigated or reviewed the person’s needs to identify if any changes were required to prevent the incident happening again. We found where issues had been identified, action had not been taken to address known issues. The local authority had visited the service prior to our assessment and highlighted areas for improvement; we found little action had been taken to address those issues. This meant people were at an increased risk of receiving poor care.

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. Whilst we found staff assessed people’s need prior to moving into Eastwood House, we found some people had limited care plans in place for care staff to follow. For example, we found a person who lived with diabetes had no care plan in place relating to the management of this condition. This meant staff had no guidance in how to support the person with their diabetes or recognise if there were changes in their normal condition.

We also found where a person became distressed there was no care plan in place to guide staff in how to support the person to manage periods of distress and anxiety. This meant staff had no guidance in how to support the person safely.

People and their relatives told us they felt safe living at the service and staff supported them to seek advice and support from other healthcare professionals when needed. We found senior care staff referred to external professionals and discussed advice during handovers. This meant care staff were aware of advice provided.

Safeguarding processes in place needed strengthening to ensure people were protected from the risk of harm. We found staff received safeguarding training; they could explain what safeguarding meant and staff reported incidents to the registered manager. However, we found the registered manager did not always report safeguarding concerns to the local authority or CQC. This meant there was an increased risk the incident could re-occur.

We also found staff were not aware of who had lawful restrictions in place and who did not. This increased the risk people could be restricted unlawfully which is a safeguarding concern.

All people and their relatives told us they felt safe living at Eastwood House, a relative we spoke with said, “My [relative] is safe, if they were not I would move them.” Another relative we spoke said if they had any safety concerns they would raise these with the senior care staff, they advised they had raised safety concerns in the past and the senior care staff had resolved issues.

The provider and registered manager did not always ensure staff supported people safely. We found staff did not have clear guidance in place to ensure people were supported in a safe way and according to their needs. For example, pressure area care was poorly managed which placed people at an increased risk of harm. We found people were not repositioned in line with their assessed needs to prevent skin damage. We found a person living with pressure damage had conflicting information recorded within their care plan. This meant staff did not have accurate information in order to support them safely.

All of the people and the relatives we spoke with told us they had not been involved in the care planning process, this included people who had legally appointed relatives to make decisions on their behalf if they were not able to do so themselves. A relative we spoke with said, “My relative has not seen a care plan, and no one has discussed one with them or me.” This meant people were at risk of receiving care not aligned with their needs or wishes.

The provider did not always 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. We found open stairs which were accessible to all people including those with a cognitive impairment and at risk of falls. There were no risk assessments in place to address this risk, this meant people were at increased risk of harm.

We found Personal Emergency Evacuation Plans (PEEPs) to be inaccurate, we found they did not provide staff or emergency services staff with sufficient detail to safely support people in the event of an emergency evacuation. This placed people at an increased risk of harm. We fed this back to the provider who took action to address the issues raised.

Checks to the environment were carried out to ensure the building was safe. For example, the provider ensured inspections of heating systems were carried out by qualified professionals yearly. Wardrobes and other heavy furniture were secured to walls, this prevented furniture from tipping and falling on people and staff. We found the building to be secure which prevented people at risk of leaving the building alone from harm. People told us they felt safe in their environment.

The provider did not always make sure there were enough qualified, skilled and experienced staff.

Staff were kind and caring, however we received mixed feedback from people about the number of staff on duty. A person we spoke with told us, “There could be more staff at times.” Whereas a relative we spoke said, “There is enough staff, nothing to suggest there is not.” Staff also provided mixed feedback, a staff member we spoke with said, “We definitely need more staff, it’s hard when people need you,” however, another staff member we spoke with said, “Staffing is not an issue here.”

Records showed staff received training and people felt staff were skilled, however we found there were no staff trained in administering medicines allocated to work during the night. This meant if people needed medicines in the night they would need to wait for a member of the on-call team to come in. We fed this back to provider who took immediate action to address this. Recruitment processes were followed to ensure only suitable staff were appointed. Checks including, interviews, references and Disclosure and Barring Service (DBS) checks were conducted before staff started working at the service. DBS checks provide information about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Staff approached and supported people with kindness.

Infection and prevention control measures in place were not effective. Parts of the home were not clean. We found areas of the home to have cobwebs and large amounts of dust present. We also observed furniture to be unclean and damaged. Which meant it could not be cleaned effectively. Equipment used to aid people’s mobility was unclean with visible debris. Infection prevention and control processes were not effective in identifying issues within people’s bedrooms, duvets, pillows and cushions which were in use were stained with bodily fluids. We found sink taps in the home had a build-up of limescale which creates an environment for legionella and other waterborne pathogens to accumulate. This meant people were at an increased risk of contracting infection through poor infection prevention and control practices. People and their relatives raised no concerns regarding the cleanliness of them home.

Medicines were not always managed safely. We found topical medicines were not stored safely some of which were accessible and unsecured in people’s bedrooms. This placed people living with dementia at risk of harm if they had access to these products and ingested them.

We found topical medicines were not always dated with an open date. Which meant staff did not know if these were safe or effective to use. We also found creams prescribed for a person to be in the wrong person’s bedroom. This meant there was a risk that people could receive cream not prescribed for them. We fed this back to the provider who took immediate action to ensure topical creams were stored safely.

Medicines were not always stored in line with guidance, the room in which medicines were stored regularly exceeded recommended temperatures, whilst staff were aware of this no action had been taken to address this. This meant there was a risk medicines could become less effective.

People and their relatives told us they received their prescribed medicines safely and staff acted when people required medicine for pain. A relative we spoke with said, “Staff listen about pain management, and they give [medicine name] when pain is really bad.” Our observations supported this, we observed a person in discomfort, staff enquired about their well-being and provided pain relief without delay. Staff had good knowledge about ordering medicines, this meant no one ran out of their prescribed medicines. Only staff trained in medicines administration who had their competency assessed administered medicines to people. As detailed within this report there were no staff trained to administer medicines allocated to work during the night. The provider had an on-call system, where trained staff would attend the home if a person required medicines. This meant people may have to wait for their medicines, we raised concerns about this process with the provider and they took immediate action to resolve this issue.