Eaton Lodge Nursing 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 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 people’s safe care and treatment including medicines administration and ensuring the premises are safe for people.

This service scored 59 (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.

When incidents occurred, they were reported and investigated. Action was taken to address concerns and reduce any risk of an incident from re-occurring. For example, following an incident of choking, one person was referred to the speech and language team for a swallowing assessment and adjustments were made to the persons diet to reduce the risk of further concerns arising.

The registered manager had an overview of incidents and concerns were shared with people’s families where appropriate. One relative told us the equipment their relative used was changed following a fall. They said, “They are doing everything they can to minimise the risks.”

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 were well supported when they moved into the service or transitioned between services. One relative told us, “Eaton Lodge were great at liaising with [the] Hospital, when they discharged him to Eaton Lodge and brought him by ambulance. Everything since then has been really good.”

Relatives also told us people were also well supported with other areas of health care. One relative said, “All the medical stuff they do, with the flu and covid jabs, they ask if it’s ok for him to have them. They are right on it with that stuff.”

Feedback from partners was positive, they told us the service prepared the right information when making referrals to partners. One partner told us, “I find the team to be sensible, thoughtful, and competent.”

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 protected from the risk of abuse. Staff knew how to identify and report concerns. There were systems in place to record and report concerns. If concerns had been raised these had been shared with the local authority as appropriate. Concerns had been investigated and action taken as needed.

Relatives told us they thought the care was safe at the service. One relative said, “I can’t praise them enough, I’ve never had to worry about [my relatives] care since [they have] been there.”

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, supportive and enabled people to do the things that mattered to them.

There were areas where care plans and records showed inconsistency and areas where improvement in the care provided was needed. For example, when one person had an episode of high blood sugar levels. Staff had acted appropriately encouraging the person to drink more water to lower this. However, staff had not later re-tested the person’s blood sugar levels later to check it had lowered. Care plans also did not always include information on the signs and symptoms of high blood sugar. However, staff did know how to spot these signs and relatives were positive about the support provided to people. One relative told us their loved one’s diabetes was being well controlled at the service, and the person was eating better than they had done before moving into the service. Following our visit the deputy manager met with staff to review the protocol for diabetes and ensure staff were re-testing people’s blood sugar.

Another person needed support with maintaining hydration. Staff were offering the person enough to drink, however, the person wasn’t drinking much. Staff hadn’t considered how frequently they were offering fluid to the person. Following our visit, action was taken to review people’s fluid intake and improvements were made.

Risk assessments for constipation needed to be improved to ensure guidance for staff was clear if people did not have regular bowel movements. One person was prescribed a regular ‘as and when’ medicine for constipation (PRN). Documentation showed they had been constipated for 5 days, and PRN medicine had not been offered. The person had capacity to request this medicine and to make the decision not to take this medicine. However, guidance for staff on what action they should take was not clear. There was information to support nurses to make a clinical judgement on what support the person needed but this needed more detail on what to do if the person was constipated but had no other symptoms such as pain or bloating. During the inspection people’s risk assessments were updated to provide staff with clearer guidance and ensure timely action was taken to manage this risk. Staff also discussed this concern with the persons GP, and the persons medicines was reviewed and amended which led to an improvement in the people’s condition. Staff were provided with a guided supervision to discuss how to support people with constipation and ensure staff knew what to do where there were concerns.

Other areas of care were well managed. For example, where people were at risk from skin breakdown, they were supported in line with their care plan and helped to move position regularly, where appropriate. People were also provided regular continence support where they used continence aids. This reduced the risk of infection or skin concerns.

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.

During the inspection we identified a number of concerns which needed to be addressed. One person’s possessions had been left in front of a fire exit, blocking this exit. Oxygen which was stored in the medicines room was not chained to the wall and needed to be to reduce the risk of the bottles falling over and causing an accident. There was a fire exit on one floor which led to the roof space. The door alarm was not working so staff would not be alerted if a person left through this door. There were also areas where doors were left open and items which could cause harm were accessible to people. For example, the laundry door was not always kept locked and cleaning products were accessible. This could pose a risk to people living with dementia if they accidentally ingested or splashed some chemicals. One hot water tap was too hot and there was a risk a person could be scalded if they used this tap. We raised these concerns with the deputy manager who arranged for them to be addressed during the inspection. However, concerns should have been identified and addressed prior to the inspection.

Regular health and safety checks were completed such as ensuring the lift was safe to use, checks on call bells and utilities. However, these had not been effective in identifying all hazards in the environment. Staff had completed relevant training such as fire safety training and food hygiene.

The provider had made sure there was enough staff to support people. However, some checks on staff training had not been completed. Staff received effective support, supervision and development. Staff worked well together well to provide care that met people’s individual needs.

There were enough staff to provide people with the support they needed to keep people safe. One relative told us, “There always seem to be someone about. They’re never rushed.” Staff told us they had time to sit and talk to people, and we observed this to be the case.

Staff had completed the training they needed to provide people with support. For example, learning about safeguarding people, diabetes care and supporting people with their mental health needs. However, staff competency checks for manual handling had not been completed to ensure staff practice continued to be safe. The registered manager commenced undertaking these checks immediately after the inspection. Other competency checks such as checks on medicine administration and catheter care had been completed.

Staff received regular supervision and told us it was helpful and supportive.

Recruitment checks had been carried out to ensure that staff were recruited safely. For example, to make sure Disclosure and Barring Service (DBS) checks had been completed. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

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 was visibly clean and was free from any odour. There were schedules in place to ensure the service was kept clean. Cleaning staff told us they had enough time to complete their role.

Staff wore personal protective equipment (PPE) when needed and changed PPE appropriately. Staff had undertaken relevant training such as training on infection prevention and control and COVID 19. Spot checks on staff practice were undertaken to ensure staff were following correct procedures. Staff knew what to do if there was an infection outbreak and who to inform.

Feedback from people and their relatives was positive. One relative told us, “There’s no smell. It’s spotlessly clean.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs. People were involved in decision about their medicines.

There was a system in place to rotate people’s skin patches, such as patches to help manage pain. However, when this system was not followed there was no risk assessment in place to provide staff with guidance. For example, one person chose not to rotate their patches in line with the guidance in the patient safely leaflet. The person had the capacity to make a decision about this, however there was no risk assessment in place to support this. For example, to ensure the person was fully aware of the risk and that staff were monitoring the person skin for concerns. This was put in place during the inspection.

Where medicines were administered covertly staff had checked they could be safely crushed. However, one person had one medicine which could not be crushed. This was not clearly identified on the instructions for staff and staff told us they had crushed this medicine. This meant there was a risk the medicine would be absorbed too quickly. We raised this with the deputy manager during the inspection. They liaised with the persons GP and ensured staff stopped crushing this medicine.

People’s medicines were stored safely either in the medicines room or in a locked trolley which was chained to the wall. Staff ensured the trolley was kept locked when they were busy administering medicines. Medicines were disposed of safely.

Medicine stocks were well managed, and staff ensured people had their medicines when needed. Medicines were dated when they were opened and expiry dates were made clear to ensure medicines were not used for longer than they should have been.

People and their relatives told us they had no concerns about how people’s medicines were managed. One relative told us, “They did a complete review with the doctor of what [my relative] needed, they oversaw it. They bring her medication, I’ve no concerns.”