Escan Manor

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 Requires Improvement. At this assessment the rating has changed to Good.

This meant people were safe and protected from avoidable harm.

The provider was previously in breach of the legal regulation in relation to safe care and treatment and safeguarding. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.

This service scored 63 (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 occurred, these were recorded and reviewed by management and then a monthly analysis completed to look for themes, trends and lessons learnt.Where required, people were referred to external healthcare professionals for assessment or to provide equipment to reduce the risk of further incidents.Staff we spoke with were clear on the reporting processes for falls, accidents or incidents.

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.

There were systems and processes in place that ensured appropriate pre-admission assessments were completed. This helped ensure Escan Manor would be the most suitable place for the person to live and that staff could meet their assessed needs. Care records showed where healthcare partners had been involved in people’s care and treatment to improve outcomes.

The provider had a process in place to ensure continuity of care. For example, if a person was admitted into hospital, the relevant and key information the hospital staff may need could go with them.

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.

At our previous assessment, we identified the provider was managing a high number of safeguarding concerns. Although the provider was working with the local authority, they had not ensured people were safe in a timely manner. At this assessment we identified improvements had been made and the provider was no longer in breach of regulation, however further work was required to ensure current systems and processes were fully effective. The service maintained a safeguarding log; however, this was not fully maintained to show the outcome of alerts or concerns raised. There was no indication if safeguarding concerns raised had been substantiated or if the investigation was closed.

Staff were able to clearly describe to us how they would identify potential abuse and what action they would take to escalate this appropriately. No concerns were raised by people or their relatives about the care and support they received from staff.

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 a procedure called 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. The service had submitted DoLS applications and these were currently pending with the relevant local authority.

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.

We identified concerns around risk management for some people’s Personal Emergency Evacuation Plans (PEEP). We identified in 1 person’s PEEP the information was not accurately reflective of the level of support they would require in an emergency. In addition to this, the main list showing who was currently living at the service within the fire evacuation bag was inaccurate. This meant that staff may not have reliable information about which individuals were present during an emergency, potentially delaying evacuation procedures and increasing the risk to people’s safety.

The provider completed risk assessments where risks to people’s health and safety were present and created care plans to guide staff on how to support people to manage those risks.Care plans were detailed with information for staff on how to avoid potential triggers in relation to known risks, for example triggers which may cause a person to become distressed or agitated. Care plans detailed how staff should recognise and support people. This personalised information demonstrated people were at the centre of risk management.

Records showed and staff told us that when people needed specialist support to manage risks to their health and wellbeing, such as a risk of choking or falling, this was arranged.People at risk of malnutrition and dehydrated were having their food and fluid intake monitored to identify emerging risk.

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 identified that improvements had been made following our last assessment. There were now appropriate systems and processes in place to safely manage the environment. There was a new member of staff employed to oversee the safety of the environment.

Equipment such as lifts, hoists and those related to gas safety had been inspected in line with requirements. Each month, safety checks were completed by a dedicated member of staff on equipment used to support people, such as call bell systems, wheelchairs and walking aids. Records showed legally required checks of mobility and lifting equipment had been completed.

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 consistent care that met people’s individual needs.

We received mixed feedback from people and staff about staffing numbers at the service. Feedback from people was generally consistent that they felt the service was understaffed, particularly at weekends. People told us they sometimes had to wait for care and support from staff when they rang their bell. One person said, “It depends on the time of day. Weekends are not good.” A relative we spoke with told us, “One of the things that does concern me is staff numbers. They do their best however weekends can be sparse.” Staff did not raise any significant concern around staffing levels but told us unplanned sickness was frequent and had an impact on care delivery. We communicated the feedback from people to the provider and service manager who advised us this would be reviewed.

There was a process in place to support new staff on induction, and we saw records to support this. New staff also completed a period of shadowing more experienced staff. We received mixed feedback about the induction quality from staff. The registered manager had a training matrix in place which evidenced where staff had completed their mandatory training. Supervisions were taking place and staff we spoke with confirmed this. The provider followed safe recruitment practices. Appropriate checks were completed before staff began working at the service to ensure they were suitable to support people living there.

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.

Staff were trained in infection prevention and control. Staff understood when and why they should use personal protective equipment (PPE) and we saw this was readily available throughout the building. No concerns were raised by people’s relatives or healthcare professionals in relation to the cleanliness of the environment.

The environment was clean, and there were no malodours; housekeeping staff were on duty. The registered manager and provider used auditing systems and processes to monitor the cleanliness of the service.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

At our previous assessment, the provider was in breach of this part of the Safe care and treatment regulation. At this assessment we identified improvements had been made and the provider was no longer in breach of regulation, however there were some ongoing improvements required.

There were suitable arrangements for ordering, storage and disposal of medicines, including those needing cold storage and for controlled drugs. Temperatures were monitored to make sure medicines were stored correctly and would be safe and effective.

A new system for medicines records had been introduced. This showed that people received their medicines in the way prescribed for them, including for creams and external preparations. When medicines were prescribed ‘when required’ there was information to guide staff when these should be used, although it was not always person-centred and outcomes were not always recorded. However, staff knew people well and were knowledgeable about their medicines and needs. When patches were applied the site was not always recorded to show suitable rotation. However, a system was put in place during the inspection to ensure this would be done going forward.

Nurses had updated training and regular competency checks to show that they gave medicines safely.

People’s preferences were recorded about how they liked to take their medicines. Records were in place to show that risks were considered with higher risk medicines such as anticoagulant blood thinning medicines, but they were not always in place for flammable topical preparations. We were told by the service manager that these would be put in place for people.

Medicines policies were in place to provide guidance for staff. Medicines incidents were reported so learning could take place and reduce the risk of them reoccurring. Medicines audits took place to identify improvements and ensure any necessary actions were taken.