Estervin Court Residential 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. This is the first assessment for this newly registered service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of 3 legal regulations in relation to safe care and treatment due to inadequate care planning and risk assessing and unsafe medicines management, staffing, and fit and proper persons employed at this service.

This service scored 31 (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.

Effective systems, processes and tools to support a had not been implemented at the service.

There was no system in place for consistent analysis of incidents ensuring there were no missed opportunities to drive improvements and to learn lessons from incidents. For example, there was no investigation or detailed analysis as to what led 1 person to leave the premises unnoticed, which placed them, and others, at risk. Measures were put in place to minimise a reoccurrence, however, these measures failed, resulting in the person leaving unnoticed again.

A record of complaints was kept. However, there was no process in place to analyse and share feedback with staff to support future learning and improvements. We found shortfalls in the consistent guidance for staff around people's risks which meant a proactive culture of safety was not always demonstrated. This meant opportunities for learning and improvements in people’s care were sometimes lost or delayed.

The provider did 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.

We found 1 person did not have a pre-assessment in place, we were told this had been completed but the provider was unable to locate it. pre assessments should contains all information used in care planning and risk assessments for the person. Without it, there is an increased risk the person may not receive appropriate care of have appropriate risks assessed. We found another person had a prolonged gap in between their assessment taking place and them moving into the service, without any further assessment taking place, or an understanding for the delay.

Before people move into the service, the service works with the local authority to ensure the service is appropriate for the person, that the person is appropriate to use the service, and that the person will be able to live with others using the service. There was an extensive relevant history provided by the local authority included in the pre-assessment support plan for the people using the service.

There were handovers held twice daily that detailed relevant interactions and updates on the people living at the service. This included changes in circumstances, returning from absences, and any other information deemed appropriate by the team leader on shift.

We found the provider had made a referral to external professionals for 1 person as their needs had changed.

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

We found the provider failed to recognise safeguarding concerns and had not recognised or responded appropriately to potential abuse. They failed to carry out robust investigations into incidents and make appropriate safeguarding referrals to protect people from harm. The provider failed to recognise potential abuse, protect people from potential harm and notify relevant agencies of such concerns. For example, when 1 person left the service unnoticed, this was not reported to the local authority’s safeguarding team and measures put in place were not effective to ensure this did not occur again. For 1 person who was at increased risk of fire due to prior fire safety concerns, the provider had failed to escalate and seek further advice and put appropriate measures in place to ensure the person’s safety, and the safety of those living at the service. This incident could have caused significant harm or even death, because guidance for staff to follow was not in place. We raised safeguarding concerns due to the lack of systems to keep people safe. The provider and registered manager failed to share concerns appropriately with relevant agencies, teams and professionals which was confirmed by the local safeguarding team as the safeguarding’s had not been raised with them.

The training matrix indicated all current care staff had completed training in safeguarding and the Mental Capacity Act (2005). However, we found the maintenance team had not received any onsite training, although they had direct access to private rooms. People told us they felt safe with the staff supporting them.

We found 1 person had an authorised Deprivation of Liberty Safeguard (DoLS) in place. This included conditions which had not been actioned, meaning the provider had failed to act and adhere to the legal requirements.

DoLS ensures people who cannot consent to their care arrangements in a care home or hospital are protected if those arrangements deprive them of their liberty. Arrangements are assessed to check they are necessary and in the person’s best interests.

The provider had appropriate policies and procedures in place for safeguarding the people using the service, but care staff did not know how to access the policies.

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

The provider did not consider or take into account the risk some people living at the service posed to other vulnerable people also living at the service.

We identified staff were not always provided with clear information and guidance in relation to risks, which put people and staff at increased risk of harm.

We found some known risks to people had not been assessed and further information for staff was needed about how the risks would be managed.

We found 1 person’s current risk assessments were more than 2 years out of date.

We found some care plans lacked accurate details. For example, 1 person’s care plan included information for type 1 diabetes when the person had type 2 diabetes. This reduced clarity for staff supporting people and increased the risk of care being provided inappropriately.

We identified from people’s files we checked, all had completed reviews, but the care plan and risk assessment reviews were mostly outdated or unsigned by the person or a staff member. The provider was unable to evidence people had been involved in the reviews of the care they were receiving.

We found relevant daily information was not always recorded for people using the service. There was an electronic notes system in place, but staff confirmed it was not always used and sometimes information was given on the shift handover instead. For example, when an incident had occurred, we found this had not been sufficiently recorded on the electronic notes system but was evidenced on the shift handover notes. If information is not recorded at the time of it happening, it increases the chances of it not being recorded, and potential incidents not being investigated, putting people at increased risk.

We found staff were knowledgeable on how to support people who communicated signs of distress, and the different de-escalation techniques which worked well for people. Staff were able to describe how each of the people’s behaviours could change depending on their mood, but this information was not available in people’s files.

One person we spoke with confirmed they were happy with the support they were getting and that they were included in the planning of their care, that the ‘staff are nice and they got on really well with them’.

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 found appropriate safety certificates were not in place. The electrical wiring certificate expired 1 month before the inspection. The portable electrical equipment test certificate had expired in April 2025 and the fire alarm certificate expired in October 2024. The provider had failed to carry out any risk assessments to mitigate these risks.

A fire risk assessment was carried out in May 2025 and an action plan was put in place to action the concerns raised in the risk assessment. Although the action plan showed all concerns raised had been satisfied, we found this to be incorrect as 2 of the concerns raised on the fire risk assessment had not been repaired. The fire panel was still showing a fault, and there were still 2 emergency lights not working.

The fire evacuation plan did not provide enough information to safely evacuate people from the building; 1 person living on the first floor required a Mobility-Evacuation chair to get down the stairs in the event of an emergency, but there was no Mobility-Evacuation chair in the building.

We identified several environmental risk assessments had not been completed, including for the building extension taking place. We identified that people’s risk assessments did not always consider environmental risk.

We found the health and safety checks were not to the required standard and some rooms had not had legionella checks or water temperatures checked in over 10 months. This is not in line with national guidance and placed people at increased risk of hot water burns in their rooms

The provider did not 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 work together well to provide safe care that met people’s individual needs.

The provider did not always ensure they had assessed staff to have the skills and training needed to fully carry out their roles.

We reviewed staff training records and found not all staff had fully completed their induction training, or their Care certificate. The care certificate supports staff that are new to care to ensure they have the foundation skills to provide good care.

Not all staff had received training in specific topics needed to carry out their roles, this included maintenance staff.

We reviewed staff files and found the service did not have records available for an agency staff member in regard to their training, DBS or references.

Staff recruitment processes were not always robust. We found staff files where gaps in employment history had not been recorded, applications forms were incomplete and relevant qualifications had not been seen. 1 staff member did not have a staff file. The provider failed to induct agency staff which meant agency staff were not familiar with procedures to follow in the event of an emergency.

The provider had recruitment files for all care staff on site. There was a completed application form with 2 references, evidence of police checks, completed health questionnaire, and proof of identification in place for all care staff. We found that, for 1 staff member, not all gaps in employment history had been investigated, relevant qualifications had not been seen, and copies of the qualifications were not in their staff file. The staff files for the maintenance team were incomplete. One of the files did not have a completed application form, references, identification, health questionnaire or training completed. The other member of staff did not have a staff file.

We checked an agency staff member’s file and there was no information available on training given, DBS or references checked.

The provider completed all training onsite with the training materials supplied from an external company. All staff received appropriate training however we found a lack of competency checks in place for staff, including when staff had not passed their initial training.

We found a lack of evidence of staff supervisions or appraisals being completed at regular intervals.

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.

The provider did not always make sure the premises was clean and tidy. We observed completed daily cleaning schedules that had been signed off by the manager on duty but were unable to see evidence the cleaning had taken place. We observed large cobwebs from curtains and mould on the PVC windows in the main kitchen.

On assessment of the kitchens, we found the temperature checks book for the refrigerator had not been properly maintained. Food stored in the refrigerator did not always have an opened date applied to the packaging, and we found food with expired ‘use by’ dates. The local authority had carried out an environmental assessment of the kitchen in August; however, the provider had failed to implement the recommendations.

We observed staff to not always follow best practice guidance and were seen wearing clothing below the elbow and not changing their gloves and aprons between tasks. There was insufficient stock of aprons, and hand washing materials available in the kitchen.

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.

Medication Records and Medication Administration Record (MAR) charts were not always completed. We found medicines did not always have a date of opening applied to them. Which meant the provider could not be assured they were being used within the correct timescales once opened.

There were no protocols in place for ‘as required’ medicines. This meant staff had no guidance on when to safely and appropriately administer medicines. For example, for 1 person who was prescribed 3 different pain-relieving medicines to be used as and when required, there was no guidance on which should be used first or how to assess if stronger pain relief is required.

There were no medicines audits taking place. Medicines were being ordered inappropriately and the process around recording medicines and returning medicines was not always documented or updated. This increased the risk of medication errors and potential for overdosing people.

Although there was always a member of staff on shift who was trained in administering medicines, medicine competency checks had not taken place. This meant the provider could not demonstrate they had observed safe practices in administering medicines.

Medicines were not always stored appropriately. Controlled drugs were stored with general medicines and opened medicines requiring refrigeration were stored with unrefrigerated medicines, in the general medicine’s cupboard.

We observed crushed medicines being given without the appropriate assessments and guidance from other health professionals including the GP and pharmacist. This meant the provider could not be assured these medicines were safe to be administered in this way. There was also a risk that the person had not been supported to understand why they needed the medicine, given the right to refuse the medicine or that decisions had been made in their best interest in the least restricted way.