Mount Ephraim House

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.

This is the first assessment for this newly registered service. This key question has been rated 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; the way people’s medicines were managed, and staffing.
 

This service scored 41 (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 always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

An overall view of accidents and incidents, to learn lessons and keep people safe by ensuring the appropriate mitigation measures were in place, had not been undertaken.

Although staff recorded incidents that happened, some people’s care records were not always updated to ensure changes were made to the way they were supported to avoid a re-occurrence. For example, some people had a fall resulting in injury, but their care plans and risk assessments were not updated in a timely way to avoid the risk of it happening again. Although investigations had taken place into individual incidents, the provider had not identified patterns and trends or acted to reduce further risks to people. A culture of learning lessons was not evident.

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.
Risks to people were not always appropriately assessed and mitigated against and their care needs were not always described well to enable individual care. Permanent staff knew people well but there were risks people may not receive safe or appropriate care when being supported in a different setting such as when admitted to hospital for treatment, by staff who did not know them well and their needs and risks were not adequately recorded.
People had been referred to the appropriate healthcare professionals, such as GP’s and occupational therapy when needed. This meant a joined-up approach could be taken to providing people’s care.
 

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. People’s rights were not always upheld.

Where relevant, a Deprivation of Liberty Safeguards (DoLS) application had been made when people had been assessed as lacking the capacity to consent to their care and treatment at Mount Ephraim House.
Where a DoLS application had been authorised, this was sometimes subject to conditions that the provider must comply with. Relatives told us conditions of a DoLS authorisation for their relative had not always been complied with. A relative said despite raising their concerns on more than one occasion with managers and senior managers that a condition of their loved one’s DoLS authorisation was not being met, they did not get a satisfactory outcome and the condition remained unmet.

Incidents had been referred to the local authority appropriately in line with safeguarding vulnerable adults’ protocols. Staff had raised concerns when they should, and these had been raised externally.
People and their relatives told us they felt safe with the care and support they received. Comments included, “Yes, I do (feel safe). I think the staff do a marvellous job, as they need a ‘Sara Steady’ to move from her bed to the armchair or to their wheelchair. When they are moving, there are always 2 carers about to help them and ensure it is done safely.” and “Yes, it is very good indeed. We are very happy with the care that (Loved one) is receiving.”
 

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.

Staff did not always have the guidance necessary to keep people safe while at the same time supporting enablement and independence.
Some people’s care plans and risk assessments were detailed, providing individual information about how people liked to be supported, what they liked and helped them to feel safe and what they did not like. Staff, including agency staff, had the guidance they needed to support some people in a way that was safe and how the person preferred to be supported. However, other people’s care plans and risk assessments were not individual to their needs which meant there was a risk of potential harm.
A care plan was in place for a person who at times became distressed, including during staff support with personal care. The risks associated with their distress was not individual to the person, they were generic risks, generated by the electronic system. This meant staff may not be using safe and consistent techniques to reduce the person’s anxieties. Incident records showed staff had been scratched, however, risk assessments had not included specific guidance for staff to prevent avoidable anxiety for the person and staff being harmed.
Some people were assessed as being at risk of choking. The risk had been identified, however, there was no guidance for staff about what they should do if the person started to choke, addressing each person's individual circumstances. For example, if they were mobile, or if they ate their food while in bed.
 

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.

The provider had not ensured risks within the environment had been safely managed, placing people at risk of harm.
A large hot water urn installed in the dining room was extremely hot to the touch, creating a serious risk of burns. A risk assessment had not been undertaken to prevent harm to people, relatives and staff. We pointed out our concerns on our 1st site visit day and although a risk assessment was developed, this did not highlight all relevant risk areas. On our 2nd visit, we found the urn was still extremely hot to touch with no mitigation to prevent burns in place. When we again pointed out our pressing concerns, staff turned the urn off until a safer system for providing hot water for drinks could be established.
Cleaning products were left in unlocked kitchen cupboards in areas accessible by people, posing a potential risk of harm. Body creams were left in an unlocked drawer in a communal lounge, creating a further risk. Staff removed the creams and the cleaning products when we drew their attention to them. The provider had not recognised the risks before they were pointed out to them.
There was a range of equipment to help people move around their home such as hoists. Equipment was serviced regularly to make sure they were safe to use.
People told us, “It's a lovely place to live, well-furnished and fitted out, there's a nice garden also” and “It’s nice here, it looks lovely.”
 

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

There were a significant number of permanent staff vacancies, leading to a high use of agency staff across all care shifts including senior care staff. This increased the risk of inconsistency in staff practice when providing people’s care, increased further by the lack of appropriate guidance in some people’s care records about their specific care needs.
People and their relatives were overwhelmingly concerned about the staffing situation and use of agency staff, which they said impacted on their care and quality of life. The comments we received included, “There’s not enough staff – Especially evening and weekends” and “I think there are too many agency staff. (Loved one) is always saying that there is someone different in their room. They do not know what any of the different uniforms mean as nobody has told them or me for that matter. I think they know what they are doing, but I question whether they are doing it the whole time. I think a lot of them are often in a rush as there are quite a lot of residents there.”
Although the service was clean during our visits, added pressure was placed on all staff due to the regular shortage of cleaning staff and laundry staff on duty. Often only 1 domestic staff was on duty to cover 3 floors and at times no laundry staff.
Staff had not received the training and support to increase their skills, and to monitor their performance. Over half the care staff team had only 1 supervision meeting with a line manager and some staff had none in 2025. This was not in line with the provider’s own policy. There was a risk without effective supervision staff’s performance, skills and ability may not meet the required standards to ensure people’s safety or identify appropriate support if improvements were needed.
Staff had not been trained to carry out their roles in specific areas, such as catheter care, Parkinson’s disease and diabetes.
Staff had been recruited safely; the required checks had been completed to make sure staff were of good character.
 

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.

Although we found the service to be generally clean when we visited, relatives fed back that they did not always find their loved one's bedrooms and bathrooms to be clean when they visited. The regular shortage of domestic staff on duty increased the risk of some areas not being cleaned as thoroughly as needed, which increased the risk of infection.
Relatives told us, “I don't have any issues with the communal areas being clean and tidy.
I have never thought when walking into (Loved one’s) room that it needs a clean and a dusting, but I do with the bathroom, and the toilet in particular. Every time I go in the bathroom, I must flush the toilet, and it often needs a clean” and “It is not always clean. We have on occasions reported to the managers and seniors that (loved one’s) room needs to be cleaned including the bathroom. The dining room on the first floor is disgusting - the fridge is filthy, dirty cups in the sink and tea and coffee drips all around both the sink unit and on the floor. We have on occasions also seen left over breakfast plates and bowls still on the tables.”

People however told us “I like the environment. It is extremely friendly and the staff there if they can help you, they will” and “I think that is very good. I have not seen instances where there have been any concerns about cleanliness.”
 

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 their medicines support.

Staff responsible for administering people’s medicines had not completed the necessary training and competency checks in line with the provider’s own policy. People could not be assured they were receiving their medicines safely.
Staff who were responsible for administering people's medicines were required by the provider to complete medicines training annually and to have their competency assessed 3 times in a 12-month period. This had not happened. Errors had occurred and there were no assurances all staff who administered people’s medicines were competent to do so.
Some people had been prescribed medicines to take only when required, such as painkillers. Guidance was not always in place for staff to make sure the medicines were administered safely, such as when to give the medicine and the safe dosage.

There was conflicting information regarding a person’s medicine. The medicines administration record (MAR) recorded how many times a day the person should take the medicine, yet the medicine box supplied by the pharmacy stated a different number of times a day. This had not been identified by the provider. There was a risk the person was not receiving the correct dosage which may have impacted on their medical conditions.

People told us their medicines were often an hour late. Some people needed to wait an hour after taking their medicine before having food, which meant their breakfast would be later than they wished.