Egerton Manor 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.

This is the first assessment for this service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

People and staff were encouraged and supported to raise concerns and staff felt confident they could do this and would be treated with compassion and understanding, and would not be blamed, or treated negatively. A member of staff told us, “I feel confident and empowered by management to report all concerns if that be safety or other areas of concern.”

Risks were not overlooked or ignored. They were dealt with willingly as an opportunity to put things right, learn and improve. The staff survey from 2024 stated 96% of staff felt concerns would be fully investigated.

We saw evidence of leaders reviewing accidents and incidents, including serious injuries, in clinical governance meetings. Leaders reviewed themes or trends from incidents and agreed appropriate actions such as requesting staff re-review certain practices with the support of their seniors.

Lessons were learned from safety incidents or complaints, resulting in changes that improved care for others. Staff told us lessons learned from safety incidents or complaints were shared during handovers, daily huddles and staff meetings.

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.

Safety and continuity of care was a priority throughout people’s care journey. This happened through a collaborative, joined-up approach to safety which involved the provider, along with staff and other partners in their care. This included referrals, admissions and discharge, and where people were moving between services. New people transitioning into the home were discussed by leaders in flash meetings and this information was then shared with the wider team.

There was a strong awareness of the risks to people across their care journeys. The approach to identifying and managing these risks was proactive and effective. Staff told us how they recorded any concerns or changes such as pressure sores and the general wellbeing of people within the persons care notes. We also saw evidence of hospital admission documents being completed.

Care and support was planned and organised with people, together with partners and communities in ways that ensured continuity. The views of people who used services, partners and staff were listened to and acted upon.

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.

Staff had a good understanding of safeguarding and how to take appropriate action. Staff were able to outline indicators of abuse and the required actions if a safeguarding concern was identified. All staff we spoke to confirmed people were safe and well cared for.

People told us they felt safe. One person said, “I am safe because the girls are always there for me,” whilst another person said, “I am very safe here. My family couldn't keep me this safe because they are not able to be there all the time. I am treated very well.” Staff supported people and their relatives to know how to raise concerns when they did not feel safe, or when they had concerns about the safety of other people. The residents survey from 2025 documented 100% of people felt safe.

There were effective systems, processes and practices to make sure people were protected from abuse and neglect. The provider had up-to-date safeguarding policies in place which provided staff with details of how to report safeguarding concerns. Staff made safeguarding referrals when required and leaders identified actions following safeguarding concerns being investigated. The provider ensured external bodies such as the CQC were informed of any safeguarding concerns in a timely manner.

There was a commitment to taking immediate action to keep people safe from abuse and neglect. This included working with partners in a collaborative way. We observed posters throughout the care home which provided staff and others with contact details for the local authority if they had concerns about an adult at risk.

The provider understood and applied the legal framework designed to protect people who lacked capacity to make decisions or needed to be deprived of their liberty. They ensured staff received relevant training and we saw appropriate record-keeping. People were supported to understand their rights, including their human rights, rights under the Mental Capacity Act 2005 and their rights under the Equality Act 2010.

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.

Risks were assessed, and people and staff understood them. Risk assessments about care were person-centred, proportionate, and regularly reviewed with the person, where possible. We saw evidence of a risk assessment for a person who was shouting, instead of using their call bell, which was distressing for the person in the room next to them. Staff clearly identified actions to manage the risks and discussed these with the person. Another person’s emotional care needs had been clearly defined and an extensive list of care actions for staff to take were documented for staff to follow.

When people communicated their needs, emotions or distress, staff managed this in a positive way which protected their rights and dignity. We observed how staff had responded to a person who was emotionally distressed which had the potential to lead to physical aggression towards another person. Staff, in line with the person’s care plan, supported the person to another floor of the home, which was much quieter, made them a warm drink and spoke with them. The person who was initially distressed soon relaxed in a matter of minutes due to staff’s timely intervention.

In a care plan we reviewed, we saw staff had identified the risk of a person regularly being alone, due to their conditions and age. There was clear evidence the person was provided with emotional support on a regular basis to counteract concerns regarding loneliness and the potential impact on their mental health.

One person told us they had to be moved in a hoist and when this had occurred, they had always felt safe. A relative also told us staff when using the hoist with their loved one, did so with “care and kindness.” Another person said staff knew how to replace the equipment required due to their condition, they were impressed by staff being so well trained.

The provider had policies for restrictive practice including restraint and physical interventions and for challenging behaviour. If staff were to use restraint, it was lawful, for a legitimate purpose, safe and necessary, and staff always followed best practice. People’s care plans reflected any foreseeable risks that may needed restrictions.

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

Safety checks were completed with certification in place, to confirm utilities and equipment were safe to use; detailed records were kept of all equipment certificates and utilities supplies. Portable appliance testing was up to date and equipment was serviced as required. Facilities, equipment and technology were well-maintained and consistently supported staff to deliver safe and effective care. Regular fire safety checks and fire drills were completed. A fire risk assessment had been completed and was valid until October 2025. Some of the immediate remedial actions had not been completed but on raising these with the maintenance manager this was quickly resolved.

The provider ensured people had detailed, specific, individualised care plans regarding the environment which indicated risks and how such risks could be mitigated or lessened. Furthermore, general risk assessments for the home, which included the use of knives, animals visiting, fire doors etc. were all completed with a last review date of 2024.

People were cared for in safe environments that were designed to meet their needs. The care home was purpose-built with spacious private bedrooms, ensuite bathrooms, large lounges, bespoke balcony areas with large protective glass screens, and restaurant areas which were laid out thoughtfully with bespoke decoration and tables laid. The ground floor bedrooms had patio doors leading out to the secure, enclosed and well landscaped garden area. The care home also contained a hairdressing salon and a large spa bathroom on every floor. Corridors were wide and free from clutter and people had emergency evacuation plans in place. Each floor had 2 lifts, of which 1 was larger and used for stretchers.

The provider completed internal audits for housekeeping. The maintenance lead completed daily, weekly and monthly checks of the home. We reviewed the monthly housekeeping audits which showed good compliance. The internal monthly audit from May 2025, showed they were highly complaint in relation to housekeeping standards.

Leaders and staff considered how environments kept people safe from harm. Each room was fitted with a demisting system in the event of a fire, large equipment such as wardrobes were fixed to the walls, and acoustic monitoring was fitted meaning staff were alerted to any sounds made by people in their rooms, where people had consented to its’ use.

The provider was considerate to people’s needs, for example, silent call bells had been fitted to prevent people consistently being disturbed, and towels, sanitary pads and other equipment of this nature were stored on a ‘dignity trolley’ which had a covering over the top which maintained and promoted respect.

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.

There were robust and safe recruitment practices to make sure all staff, were suitably experienced, competent and able to carry out their role. Leaders recruited staff safely, with all necessary checks and documentation in place. Application forms were fully completed, and at least 2 references were obtained prior to a starting work. Interview questions and answers forms were kept. UK disclosure and barring service (DBS) checks were completed to ensure staff were of suitable character to work with vulnerable adults.

Most staff we spoke with felt there were appropriate levels of staffing, however some felt this was not the case and commented on how their breaks were often much later than expected due to the demands of the role. A staffing dependency tool was used to determine how many staff were needed each day.

The residents survey from 2025 documented how 90% of residents felt staffing was either outstanding or good. Furthermore, 100% of people felt staff were knowledgeable and qualified.

Staff received an appropriate induction which included shadowing and 6-week and 12-week check-ins with a team leader, which we saw evidence of.

Staff had completed the relevant and necessary training for their roles. Staff had achieved 100% compliance for mandatory training and 96% compliance for additional dementia training. The provider ensured staff had access to supervision.

The turnover of staff between May 2024 and May 2025 exceeded 80%. We raised this with the registered manager, they explained this was part of the natural evolution of building a strong and committed team for a newly registered service. The registered manager embraced the level of turnover as an opportunity to build a high-quality, person-centred workforce. It was also evident there had been a significant reduction in staff turnover in May 2025 and it was predicted to remain low.

The provider did not always ensure annual appraisals were completed in a timely manner. We saw evidence of staff who had started working for the service in 2023 who had yet to have an appraisal.

The provider assessed and managed the risk of infection and shared concerns with appropriate agencies promptly.

There was an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. People were protected as much as possible from the risk of infection because premises and equipment were kept very clean and hygienic, and there were no offensive odours. Housekeepers completed daily and weekly cleaning schedules which were signed and dated to show they had been completed.

The provider completed internal audits for infection prevention control (IPC). A leader completed a daily walkaround to identify any IPC concerns. The provider ensured there were monthly internal IPC audits and hand hygiene audits. In May 2025, the service was highly compliant in relation to IPC standards. The regional support manager also completed a more in-depth IPC audit bi-annually; the most recent was completed in January 2025 and the service was highly compliant. Officers from Bolton local authority had also completed an inspection regarding IPC in February 2025, and the home had scored 100%.

There was an up-to-date policy on the control of infection, which staff could refer to if needed. Staff were trained in IPC and had access to personal protective equipment (PPE). We observed staff were bare below the elbow and wore PPE, when applicable, to help prevent the spread of infection.

There were sluices on every floor with hand washing sinks and hand sanitising stations throughout the home. IPC signage was clear for staff and visitors.

Staff used appropriate cleaning products which were stored safely, and waste materials were disposed of properly. Enough staff were employed to keep the premises clean.

Staff told us they did not have concerns regarding IPC within the home. One staff member said, “If you really care about your residents, you make sure it’s clean.” A relative told us, “The home is kept beautiful and well maintained. There are never any smells other than lovely food.”

The provider made sure medicines were administered to safely meet people’s individual needs, but we saw occasional shortfalls in medicines record keeping, including for prescribed creams.

We spoke with 2 team leaders and a nurse who had responsibility for medicines management. We reviewed medicine administration records and medicine related records for 11 people living at the home, and medicine storage.

Staff members had received training in the safe administration of medicines. Managers completed staff competency assessments, and medicines audits to help ensure policies were followed in practice. For example, we saw a recent audit had identified shortfalls in the handling of prescribed creams. Action plans were being developed to help bring about improvement but had not yet been implemented. We found similar inconsistencies in recording the application of creams.

Care staff worked with other professionals to review people’s medicines needs. Checks were carried out to confirm people’s current medicines on admission or readmission to the home and new medicines were started promptly. Most of the records we checked showed people were having their regular medicines administered correctly. However, we saw 2 examples where records of medicines administration had been duplicated. We also saw that for 1 person, a new allergy had not been added to the home’s records on return from hospital. We raised these concerns with managers in order that they could be further investigated, and action taken to reduce the risk of recurrence. This was immediately rectified.