The Emilie Galloway Home of Rest

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 75 (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.

The registered manager told us they operated an open-door policy which supported a culture of transparency within the home, enabling staff and families to easily raise and discuss concerns. A person told us, “Very easy to talk to management, the registered manager is amazing, her door is always open.” Systems were in place to monitor accidents and incidents. Any identified themes and trends were analysed and if needed, promptly acted upon to mitigate any future harm. For example, when people had fallen the lessons learnt form that was completed after each fall had been updated to include blood pressure checks after low blood pressure was identified as a contributing factor to previous falls. Correctprocedures were followed when reporting and recording identified risks, evidencing good practice within the home and awareness of relevant regulations. Staff confirmed they understood the protocols to follow and post falls checks that needed to be carried out to ensure people’s safety. Staff told us, “If more than 2 falls we refer to Joint Community Rehab.”

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 had an emergency transfer form, which detailed current information, and would accompany them to hospital or other healthcare settings. Prior to admission people and their families were involved in the pre-assessment process, where the provider gathered information to make the transition to a care environment an easier experience. On admission people had brought photos and things from their previous homes with them that prompted reminiscence and allowed staff to get to know them in a more personal way, which helped people to settle.

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 told us they felt safe living at Emilie Galloway Home of Rest. The provider understood their responsibilities to report any concerns and made referrals to the appropriate authorities in a timely manner. Staff confirmed they were aware of the procedures to follow should they have any safeguarding concerns. A member of staff told us, “If reporting, yes I would go to the registered manager….to the trustees if any manager concerns.” Relevant policies were in place and easily accessible for staff to reference. All people currently living at the home had capacity to make decisions and there was no need for any mental capacity assessments. The registered manager was experienced in all the necessary procedures to follow should the need arise. Families told us they knew who the registered manager was and would be able to contact them if they had any concerns they wished to discuss.

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.

Many people living at Emilie Galloway Home of Rest were still quite independent and able to make choices and go out when they wished to attend appointments or social events. However, that did not mean there were no risks attached especially relating to mobility, and staff worked to support people in minimising these risks allowing independence levels to be maintained for as long as possible. We saw that when people’s mobility needs changed then new equipment had been sourced to provide safe movement, for example using a walking frame rather than a stick or needing to use a wheelchair for longer distances. The provider had clear risk assessments in place that supported people’s independence and choice, and these were regularly reviewed and updated as required. People had capacity so could understand any information given to them and make an informed decision. This was supported even if unwise, for example someone who was a high falls risk was determined to remain independent and declined to use the call bell when mobilising, so continued to have falls trying to walk unaccompanied. Falls management support was offered and declined, but the choices the person made were respected by the staff team. The home used digital tools to give voice reminders for people who managed their own medications to help raise awareness of time and minimise any risk of medicines being taken late.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We observed the service was clean with no visible hazards. People were able to independently mobilise between areas of the home with the use of various walking aids. Fire safety equipment was throughout the home including fire extinguishers, which staff had been trained to use appropriately should the need arise. The provider employed a maintenance man who completed some of the regular safety checks, for example the weekly fire alarm tests. The service had installed a new alarm system since the last CQC assessment evidencing systems within the home were updated to stay current and in line with recommended standards. Maintenance records were up to date and included electrical appliance testing and gas safety. Independent companies were sometimes used for completing safety monitoring, such as water checks for Legionella, and comprehensive fire reports bespoke to the building.

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 and we saw evidence of pre-employment checks. These included references, proof of identity and DBS checks; the Disclosure and Barring Service, (DBS), identifies people with a criminal record or those who should not work with vulnerable adults or children. New employees completed an induction during their probationary period which included training and shadowing other staff. To support training additional competency checks were completed by the registered manager or senior staff, where relevant, for example medication administration. Staffing levels and skill mix were determined by the registered manager, and these were flexible to people’s care needs. A staff member told us, “I think we are well staffed.” All staff were supported to access training via a digital training platform, plus face-to-face sessions delivered by suitably experienced trainers. Agency staff were rarely used with management offering incentives to regular staff to work extra when required, promoting continuity of care. If ever they were needed the same agency staff would be requested, for example weekend catering staff, so they became familiar with people’s needs and preferences. The registered manager had recently sourced training for certain health conditions as they had identified this was an area that staff needed more knowledge and experience.

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 told us the home was always kept clean with one person saying, “They clean everyday even at weekends.” The home was clean and well presented, with 3 housekeeping staff working, each allocated a floor. Daily cleaning schedules were completed by housekeeping staff, one of whom told us, “We get to know the residents on our floor so when we are cleaning their rooms, we can then let the seniors know if they are not appearing well.” We saw touch point cleaning, on areas which are touched frequently, being completed on each of our visits.Staff had good access to personal protective equipment (PPE) supplies, and the service had appropriate arrangements for the disposal of clinical waste. Hand gels were available in the hallway and around the home for staff and visitors to use. The home had been given the highest rating of 5 on the most recent inspection from the food standards agency, and catering staff managed food preparation risks well. The home had contingency plans to manage any outbreaks or other healthcare risks. Those people who wished to, had been supported to access any annual health vaccinations such as the Flu vaccination and the Covid-19 booster, as and when they became available from their GP surgery. The registered manager had all relevant policies in place. There were separate staff who managed the laundry to minimise cross contamination between departments.

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.

People’s medicines were safely and securely stored. Care plans and risk assessments detailed any specific medication needs, for example time specific medicines for people with Parkinson’s disease. Medication Administration Record sheets (MARs) were clear to follow, with important information highlighted for all staff to notice. Care staff supported people with eye drops and body creams, whilst senior staff administered other medicines. Staff explained to people what they were being given, gave medicines safely, and wore PPE. Some people were able to safely administer their own medicines with minimal support from staff, and this was well managed with regular checks from the care team. Medicines audits were completed at various intervals and could be adjusted according to need. If an issue was identified the frequency would be increased. The registered manager had oversight of the monthly ordering and booking in of medicines, and the staff could easily liaise with the surgery and pharmacy as needed for any queries, or extra interim medicines that were required, for example antibiotics.