Eden Mansions 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.

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.

Where accidents and incidents had occurred, leaders anaylsed these to look for any themes and trends. They used staff meetings to discuss any lessons learnt. A staff member told us, “Nothing is perfect, but it’s a matter of discussions and improvement. If there’s a problem, nothing is hidden, we try to improve.” The provider also shared, ‘Learning through mistakes’ with staff via a newsletter, where case studies were highlighted for learning and improvement.

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.

Feedback was mixed about the involvement people had when they moved to the service. People told us, “I haven’t had a conversation with them about his care plan,” and “[Name] has been here a month. I have regular updates, and the staff are very nice. I have not seen the care plan.” Staff told us they liaised with partners to plan and arrange people’s care including temporary care for rehabilitation.

The provider had an admissions policy with a checklist which required an interim care plan and risk management plan to be put in place. However, assessments were often completed remotely rather than in person, and feedback indicated assessment information was not always accurate or complete. This could impact on the safety of the care provided. For example, one person had returned from hospital with changes made to their commissioned care, however, they required further assessment on return to the home. The provider’s procedures indicated staff were required to undertake a review 4 weeks after a person was admitted, to discuss the care plan arrangements.

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. However, the provider did not always share concerns quickly and appropriately.

Whilst systems were in place to ensure any safeguarding concerns were reported and addressed, staff needed to ensure procedures were always robustly followed. In one example whilst leaders had dealt with a complaint internally, they had not reported the concerns externally under local procedures or notified to CQC as required. The local authority had provided recent training, and the registered manager told us they were strengthening systems to ensure all incidents identified as care concerns under local procedures were reported to the local authority. The Villa managers were to receive further training in relation to this.

Staff had received training about safeguarding adults from abuse, and when to report concerns. They told us, “I have to report straight away to the nurse in charge, and if no action I have to go further up. I have no concerns of that nature.”

Feedback received indicated people felt safe living at the service. Relatives commented, “[Name] is safe, we have had conversations with the home about him being safe as he has moved from villa to villa for his benefit,” and “[Name] is safe. I visit quite a lot, and the home is safe, and she is well cared for.”

The provider had systems to understand and manage risks; however, they did not ensure staff always followed procedures and systems to understand and manage risks. For example, some risk assessments weren’t comprehensive enough to cover all aspects of risk.

The provider used door and other sensors in people’s bedrooms to alert staff to any movement. However, staff were not always clear about when these were required for each person. For example, one person’s care plan said a sensor should be switched on when they were in bed, which staff had not followed.

In other areas staff undertook risk assessments and took actions to mitigate identified risks. Staff used assessment tools and were trained to de-escalate and support people with behaviours that challenged, in relation to their mental health and/or dementia needs.

The provider had a restraint reduction policy. Staff told us they were trained to use distraction techniques, which were usually effective. They said it was occasionally necessary to support people with techniques to prevent harm. Best interest decisions and care plans had been recorded about the use of these. However, in a couple of examples the provider’s policy had not been fully followed in relation to record keeping around safe holding of people’s hands to provide personal care. The registered manager agreed to review this straight away.

The provider did not always detect and control potential risks in the care environment.

Whilst some systems were in place to assess and manage certain environmental risks, plans to mitigate risk had not always been fully followed by staff. For example, thickening powder which should be kept secure, was found in an unlocked cupboard in a communal area. Items which could pose a risk of ingestion for people living with dementia, such as shower gel and a reed diffuser in a toilet area were accessible. Whilst individual risk assessments were undertaken, the registered manager confirmed they were planning to provide storage cupboards in each person’s en-suite.

Environmental risks relating to the safety of tall furniture, including wardrobes needed to be fully assessed. The provider took some further guidance from their health and safety advisor, who recommended fixings be applied to such furniture over the next 8 weeks.

The provider ensured a fire risk assessment had been completed and a continuity plan was in place to manage unforeseen events. During our visit, we saw 2 bedroom doors propped open, which meant they would not automatically close in a fire. When we highlighted this, staff addressed it straight away. Some actions were outstanding following a fire service audit. For example, enhanced fire drills were required to be undertaken. The registered manager told us these were in progress.

The provider had health and safety certificates in place and regular maintenance checks were undertaken.

The provider made sure there were enough qualified, skilled and experienced staff who received effective support and development. Staff worked together well to provide safe care that met people’s individual needs. However, they did not always make sure staff received effective support, supervision and development.

There were enough staff to support people safely. A relative told us, “The staff are attentive. The staffing levels are good, and she is well looked after.” The provider used a tool based on people’s needs to assess the staffing levels required. Staff were available to people throughout our visits. For some people, leaders had worked with commissioners to provide one to one staffing to minimise specific risks. However, for 2 people, the registered manager agreed to review the arrangements to ensure their staffing needs were being met following some recent changes.

Staff told us they felt supported and were offered supervision meetings and received performance reviews. Various managers were responsible for conducting supervision meetings. The registered manager kept a matrix to record when these were undertaken and planned, however, there were a few gaps and periods where it had not been recorded that staff received a supervision. The registered manager agreed to review their oversight of this.

Staff were recruited safely and received suitable training. The provider had an in-house training team, and new staff completed a comprehensive induction. This included 5 days in-house training, which covered face to facetraining and eLearning. Staff received ongoing training, including supporting people living with dementia.

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 premises were clean and odour free. Leaders monitored and had acted where standards had occasionally fallen below their expectations. A relative commented, “Its modern and it’s always extremely clean.”

We saw some minor issues where lids to pedal bins kept within people’s en-suites needed to be replaced and an example where PPE had not been disposed of correctly. However, staff had received training and were able to tell us the correct procedures to follow.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were stored safely, and systems were in place to ensure people received their medicines as prescribed. Staff received training and competency checks to ensure they had the knowledge and skills needed to manage and administer medicines safely.