Eden Lodge 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.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment and safeguarding.

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. Lessons were not learnt to continually identify and embed good practice.

The culture within the home was not always focused on safety or completed lessons learnt from incidents that had occurred. For example, where accident and incident forms had been completed, we found limited evidence these had been reviewed by a person in charge or action taken to mitigate future risks. There was also a lack of evidence to demonstrate outcomes of any learning shared with staff. This meant opportunities for learning and improvements in people’s care were not always completed, implemented or embedded to protect people from the risks of harm

The provider did not have robust governance arrangements to support continuous learning and improvement. Audits and quality assurance processes failed to identify repeated concerns, and where issues had been identified, there was insufficient oversight to ensure remedial action was taken. This meant known risks remained unresolved for prolonged periods.

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.

We found transitions were not carried out thoroughly and did not manage people’s safety. Preadmission assessments were not carried out in detail and did not include people’s needs, preferences and dislikes.

Systems in place did not ensure that people were supported safely. The provider failed to have effective systems in the home to monitor people’s safety and improve records in place to support people’s continuity of care. We found people were left unsupervised for long periods of time without support. This meant people were at risk of harm because people left for long periods of time were at risk of being left when in need of help or medical attention.

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 bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

The provider failed to ensure they consistently followed safeguarding procedures or responded appropriately to potential abuse. They had failed to protect people from potential harm and report concerns. For example, where people placed themselves at risk of self-neglect this had not been identified as a risk and had not been shared with external partner agencies such as the Local Authority and CQC. We also found there had been notifiable safeguarding incidents in the home which had not been shared with the Local Authority or CQC.

We observed restrictive practice where residents were repeatedly told to sit down and they were not always supported through periods of emotional distress. This was highlighted with the provider during the assessment.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found the tracker in place to monitor who was subject to DoLS authorisations was incomplete. It was unclear when or if they were authorised, and if conditions were in place. This meant people were at risk of having unlawful restrictions in place.

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

The provider failed to manage risks effectively to ensure people received safe care. We found multiple aspects of the home were unsafe which placed people’s health and safety at risk. For example, we found people experienced falls and limited action had been taken to mitigate further falls. This placed people at continued risk of harm.

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 furniture not secured to walls which presented as a hazard to people due to the potential risk of them falling. We found shaving razors in people’s bedrooms, dirty furniture, poorly maintained communal bathrooms, unhygienic equipment and a number of radiators without covers, or with covers that were damaged. The provider told us these radiators had been turned off which minimised scald risks, however the broken covers still presented a risk of injury.

These were significant shortfalls and we have asked the provider to take action, they told us they had started to take action immediately, however on a walk around of the service later that day, many of the environmental issues remained which continued to present a risk of harm to people.

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

The provider used a dependency tool to calculate how many staff were required; however, this did not take into consideration people’s emotional needs, or the layout of the home. This meant that there was not always enough staff and people’s needs were not always appropriately responded to.

At the time of the assessment, a number of staff had incomplete or expired training. This meant we could not be assured that staff had the correct skills and knowledge to support people safely.

Staff were not always recruited safely, we found appropriate checks were not always carried out prior to employment.

When staff were asked if they felt there were sufficient staff available to meet people’s needs, one staff member told us. “No there isn't and a lot of staff that should be watching residents sit on their phone.”

These shortfalls placed people at risk of harm. We asked the provider to take action.

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.

Effective cleaning was not always being carried out, despite cleaning schedules being in place.

We found multiple cleanliness concerns in bedrooms, including dirty floors, used Personal Protective Equipment (PPE) such as gloves left on windowsills or under beds, dirty mattresses and windowsills thick with cobwebs. In communal areas, we found unsealed flooring and woodwork which had the paint removed due to bumps and scrapes which meant they could not be cleaned effectively. We also found equipment with faeces on in a bathroom which had just been cleaned by staff

Poor infection prevention control oversight and a poorly maintained environment placed people at risk of harm.

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.

We found prescribed topical creams in some bedrooms. The labels were not clear, and they had not included a ‘open on’ or ‘discard by’ date. This meant we could not be assured prescribed medicines were safe for people’s use.

Some people received ‘when required’ (PRN) medicines. We found there were not always the associated protocols in place. This meant staff did not have the personalised guidance on when to administer these medicines placing people at risk of harm.

We found some people did not receive their medicine regularly. Staff told us they believed these medicines were PRN, however the labels showed they should have been administered regularly. This placed people at risk of harm and being in unnecessary pain.

The training matrix showed staff administering medicines either had not completed training, or their training was out of date. This placed people at risk of unsafe medicines management.

We asked the provider to take action, which they started to do immediately.