Ellwood Place Dementia 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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Processes were in place to review incidents. We saw action had been taken to ensure incidents were reported in a timely manner and referred to external partners when required. We were aware of complaints the service had received and the registered manager told us how they had responded to the complainant. This provided assurance the registered manager understood their responsibilities under the duty of candour and was open with the complainant and apologised when things had gone wrong.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services. People’s wishes and needs were assessed prior to moving into the service. However, health professionals provided mixed feedback about the confidence and knowledge of staff and managers to fully meet the needs of people with advanced dementia. They told us, “The team have reported an inability to cope with the residents with more challenging behaviours, although in our assessment, their care needs have been met and risks have been managed well” and, “Staff have indicated a lack of information being passed over when a person is transferred from one unit to another.” The registered manager told us how they had identified the need to improve their assessment processes to gather further information prior to a person moving to the service and how they liaised with the relevant professionals before, during and after the admission process. Staff confirmed recent improvements to the assessment processes and the registered manager told us how they were focussing on developing the team’s confidence.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse. People and their relatives told us they felt safe and that they would speak to staff if they had any concerns. One relative told us, “Safe, yes, they have DoLs (Deprivation of Liberty Safeguards) in place [helping to keep person safe].” Another said, “[Loved one] is safe and I have faith in the [staff], they are happy carers and treat person with respect.” Staff and management demonstrated their understanding of working within the principles of the Mental Capacity Act 2005 (MCA). The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. Staff understood people’s needs and demonstrated their understanding of people’s rights to make their own decisions. For example, we observed staff helping a person with a number of choices about where and what to have to eat.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The service used an electronic care management system (ECM) which was accessible to staff at all times. Care plans and risk assessments provided details on how to safely support people in the way they preferred. Whilst this was mostly up to date, we identified a person’s care records were inconsistent in some areas. However, this did not impact the person’s support and the registered manager addressed the contradictions during our assessment. People’s care plans included health risks, such as skin integrity and the risk of falls and detailed what support people required. Staff understood how people’s needs and risks might vary day to day and were clear on actions to take to support people to remain safe. One told us, “Each day can be different. The person might be able to stand one day and not another. Sometimes people might not have an awareness of risk.” They went on to give examples as to how they supported people to manage risk. Relatives told us how they were involved in their loved one’s care plans and said, “[Health professionals visit], they are trying to sort out persons medicines. We are actively having conversations alongside [loved one], we want to know what they think and we are involved in their care planning.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Processes were in place to ensure the safety of the premises and equipment. Health and safety checks were completed, including the general environment, equipment and water checks. Specialist beds and mattresses were visually checked over with documentation to report any concerns. Risk assessments were completed for fire safety and included personal emergency evacuation plans (PEEPs) which were designed to support people in an emergency situation. People had appropriate equipment and mobility aids and could access facilities supporting their wellbeing including an onsite café. We observed people and their loved ones enjoying a drink and a chat at the café.

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. Staff were recruited safely, pre-employment checks had been carried prior to their employment, this included references, background checks and the right to work in the UK. Staff skills and knowledge were monitored through competency checks and supervisions to ensure their knowledge was practiced and embedded. One staff member told us, “We have supervision regularly and can talk about anything and everything. I feel listened to.” The registered manager told us how they had been working to develop the team and staff confirmed the service had been through a number of changes. One told us, “It was tough to start with. There were a lot of changes, but when I sat back and thought about it, they made sense.” People and relatives spoke positively about staff. Their comments included, “Staff are kind and empathetic and trying to make the residents circumstances as good as they could be” and “Staff are extremely good, very compassionate, (name) has a laugh with them”.

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. People and relatives told us they were happy with the cleanliness at the service. One relative said, “It is very clean, that was one of the things we noticed.” Another said, “It is very clean, I am really pleased.” Personal protective equipment (PPE) was available, we observed staff used and disposed of PPE appropriately. Staff followed schedules to ensure bedrooms, bathrooms and communal space were cleaned on a regular basis. Staff had received training in infection prevention and control and practised what they had learned.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. There was a policy in place to support the safe and effective use of medicines. However, this was not always fully adhered to. Whilst people had received their medicines safely, there were some shortfalls in information relating to alternative actions staff should consider or take prior to administering PRN (as required medicines). Staff did not always have access to person-centred PRN protocols to provide them with sufficient detail to make informed decisions about when and how to give a PRN medicine. During this assessment the registered manager took action to address shortfalls. Staff were observed supporting people with medicines in a person-centred manner. For example, staff knew how individuals chose to take their medicines. The service had completed assessments in line with recognised guidance for those people who lacked capacity to make decisions about medicines who required medicines to be given covertly. This included best interest decisions and agreement from health professionals and family members with the authority to act on the persons behalf.