Ealing Manor Nursing Home

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• 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 since registered as a partnership in 2024. This key question has been rated requires improvement.

This meant people were not always protected from the risk of avoidable harm.

The service was in breach of legal regulations relating to safe care and treatment (Regulation 12) and good governance (Regulation 17). We found shortfalls in risk management, staffing, infection prevention and control, medicines management and environmental safety. The provider's systems had not consistently identified, monitored or addressed these risks.

This service scored 47 (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 ensure learning from incidents, concerns, audits. External scrutiny was not effectively implemented and embedded to support sustained improvements in the safety and quality of care.

We were not assured the provider had always acted in a timely way when concerns and risks were identified by external professionals. An infection prevention and control audit undertaken in June 2025 identified concerns relating to environmental cleanliness, infection prevention and control policies, and waste management. It also identified concerns relating to clutter, worn furnishings and equipment, staff training and Legionella controls. Recommendations and timescales for improvement were agreed with the provider. However, concerns relating to infection prevention and control remained evident during our assessment.

A fire risk assessment completed in January 2024 identified actions, including several serious concerns relating to fire doors, compartmentation, evacuation arrangements and fire safety management. The provider developed an action plan and a subsequent fire risk assessment undertaken in August 2026, assessed the premises as having a tolerable level of fire risk. However, during our assessment we found fire doors wedged open and defective door guards, which indicated improvements had not been consistently embedded into day-to-day practice.

Actions arising from previous recommendations had not always been fully implemented or embedded into practice. As a result, concerns relating to fire safety, infection prevention and control, governance and staff knowledge remained evident. Staff knowledge of fire procedures, safeguarding, the Mental Capacity Act and Deprivation of Liberty Safeguards was inconsistent. This demonstrated that learning, training and improvement activity had not always translated into practice.

The provider responded to concerns raised during our assessment and developed further action plans. However, these actions were recent and had not been embedded long enough to demonstrate sustained improvement or provide assurance that learning from previous concerns had been consistently implemented.

The provider did not always ensure systems and pathways supported safe, consistent and coordinated care, including the accurate recording and sharing of information when people's care was delivered or transferred.

We found conflicting information between care plans, risk assessments, moving and handling records and Personal Emergency Evacuation Plans. Records contained different descriptions of people's mobility, levels of support and evacuation needs. For example, some people were described as mobilising with a frame in one document and as bedbound or requiring 2 staff support in another. We also identified inconsistencies between PEEPs, care plans and observed practice, including arrangements relating to bedroom doors and fire safety measures. This meant staff did not always have access to clear and accurate information to support people safely or respond consistently in an emergency. Following the assessment, the provider confirmed that the PEEPs were subsequently updated to align with care plans and to describe how people could be transferred with assistance.

Our review of PEEPs identified further inconsistencies relating to mobility status, evacuation requirements and risk ratings. Some records contained duplicated information, contradictory guidance or generic wording that was not sufficiently personalised to reflect people's individual needs. This reduced assurance that information would support safe decision-making when care was transferred, shared or delivered during an emergency.

However, staff described established admission, discharge and hospital transfer arrangements. Pre-admission assessments gathered information from hospitals, families and healthcare professionals before people moved into the service. Nurses told us transfer information, including medicines administration records, mobility information, dietary requirements and resuscitation status, was shared when people attended hospital. The service also worked with general practitioners, dietitians, physiotherapists, mental health professionals and palliative care teams to support continuity of care.

The provider did not always ensure people were consistently protected from abuse and neglect or that staff understood and applied safeguarding processes effectively.

Staff knowledge of safeguarding was inconsistent. One staff told us they were, "Not sure what safeguarding or abuse was." Another member of staff was unable to explain safeguarding procedures or their responsibilities for reporting concerns. This meant we could not be assured all staff would recognise potential signs of abuse, neglect or poor practice and respond appropriately. Staff knowledge of related legislation was also inconsistent.

Some staff were unable to explain the Mental Capacity Act or Deprivation of Liberty Safeguards, limiting assurance that people’s rights would always be appropriately protected.

Staff training records showed safeguarding training had been provided, and leaders described sharing lessons from incidents and concerns. However, staff responses demonstrated that training and learning had not always been fully embedded into practice.

However, people and relatives generally described feeling safe. One person told us they felt safe living in the home, and relatives said they felt confident leaving their family members in the provider’s care. Safeguarding procedures were in place and most staff understood concerns should be reported to managers. Leaders described working with the local authority and other agencies when safeguarding concerns arose. People's experiences were generally positive, but safeguarding knowledge was not consistent across the staff team.

The provider did not always ensure people were involved in identifying, assessing and managing risks to their safety and wellbeing, or that measures to manage identified risks were consistently effective.

Risk assessments, care plans and Personal Emergency Evacuation Plans contained conflicting information. For example, one person's records contained conflicting information about the level of staff support they required. Some records stated they mobilised with a frame, while others described them as bed and chair bound.

We found bedrails in use where associated safety measures were not always clearly documented. The registered manager told us bedrails were used for people who were restless in bed. However, risk assessments and care plans did not always clearly set out the rationale for their use, associated risks or the measures required to support their safe use.

People assessed as being at risk of skin breakdown did not always receive care in line with their assessed needs. Pressure-relieving mattresses were not always set correctly to meet people's needs. Records relating to repositioning were not consistently completed at the required times. Staff told us these records were sometimes completed later in the day rather than at the time care was delivered.

Although we found no evidence of harm, these shortfalls increased the risk of avoidable harm. Staff did not always have reliable guidance to manage risks safely. A range of risk assessments were in place and staff were aware of many risks, but assessments and control measures were not consistently clear, accurate or reviewed.

The provider did not always ensure the environment, equipment and facilities were safe, appropriately maintained and that environmental risks were effectively identified and managed.

We identified a number of environmental and fire safety concerns that had not been effectively identified or addressed by the provider. During our assessment, we found multiple bedroom and fire doors wedged open, defective door guard devices and doors that did not close effectively. This was significant because many people living at the service required staff support and specialist equipment to evacuate safely in the event of a fire.

We also found an unlocked basement area, unsecured sluice and laundry rooms, bathrooms being used to store equipment, missing window restrictors and damaged furniture and equipment. These issues increased the risk of avoidable harm.

Following our first visit on 26 August, the provider gave assurances regarding fire safety and advised remedial work was underway. However, on our second visit we found fire doors remained wedged open and further concerns relating to door guards and self-closing mechanisms. We therefore sought urgent assurances from the provider because of the risks identified.

The provider took action during the assessment. By our third visit, fire doors were no longer wedged open and defective door guards had been addressed. However, these improvements followed regulatory intervention. They did not provide assurance that environmental and fire safety risks were being routinely identified and managed through the provider's own systems.

Although action was taken, the provider had not consistently maintained a safe environment or ensured environmental risks were identified and addressed before our intervention.

The provider did not always ensure there were sufficient numbers of suitably skilled, competent and experienced staff who received appropriate support to meet people's needs safely and effectively.

Staffing arrangements were not based on a formal dependency assessment. This was despite the service supporting a high number of people who required assistance from 2 staff members and had complex mobility and evacuation needs.

Staff told us staffing levels, particularly at night, were not always sufficient to meet people's needs in a timely way. One night care worker told us, "Most nights it would be one on each floor," and when people required support from 2 staff, "Some people have to wait." Another nurse told us, "It is hard at night and we may need more staff."

Our observations reflected these concerns. During a lunchtime observation, only 1 staff member was available in a communal area. Some people waited for support with meals and drinks. On the top floor, lunch arrived at approximately 2:10pm. One person pointed towards their meal, which had been placed away from reach. We could not identify an available staff member to assist because other staff were supporting people in bedrooms.

People and relatives also told us they sometimes waited for assistance and staff acknowledged there were occasions when people requiring support from 2 staff had to wait until staff became available.

Competency assessments were not consistently completed and records showed gaps in induction documentation for newly appointed staff. The provider acknowledged competency assessments were not routinely undertaken across all staff groups and planned to introduce more formal arrangements. Medication competency assessments had recently been introduced following recommendations made during a visit by the local authority quality assurance team. Staff knowledge of safeguarding, fire safety, the Mental Capacity Act and Deprivation of Liberty Safeguards was inconsistent, which further reduced assurance that staffing arrangements supported safe care.

However, the service benefited from a stable and long-serving workforce. Many staff had worked at the service for several years and the provider did not routinely use agency staff. Staff generally spoke positively about support from managers and teamwork within the service.

The provider did not effectively assess, prevent and manage the risk of infection or consistently ensure appropriate infection prevention and control practices were followed.

We repeatedly observed poor IPC practice and environmental concerns during our assessment. Staff were seen wearing gloves and aprons in communal areas and moving between locations before removing personal protective equipment. Staff were also observed walking through corridors and entering staff areas whilst wearing PPE. This was not consistent with the provider's IPC policy, which required PPE to be changed between people and removed immediately after care tasks. Staff understanding of the provider's PPE requirements was inconsistent, and the registered manager told us staff were not expected to change aprons between people unless an infection was present.

Clinical waste arrangements were not always appropriate. On all 3 assessment visits, we found clinical waste bins in sluice rooms without clinical waste liners in place. We also observed continence products disposed of in domestic waste bins and found there were no clinical waste bins in communal toilet areas. Sluice rooms and the laundry room were left unsecured, increasing the risk of inappropriate access to potentially contaminated areas and hazardous substances.

Some utility and sanitary areas were not sufficiently clean or well maintained. We found dirty toilets, heavily stained sluice sinks, dirty utility areas and bathrooms being used to store equipment. These concerns were consistent with previous infection prevention and control findings identified by external professionals.

The provider had IPC policies, audits and PPE available. However, audits had not identified the poor practice, environmental concerns and inconsistent PPE use we found during our assessment. IPC audits could not be readily produced when requested and monitoring systems did not provide effective assurance that infection risks were being managed safely.

The provider did not always ensure medicines were managed safely and effectively or that people received appropriate support in relation to their medicines.

We found an incomplete controlled drug record and gaps in medicines administration records, including missing staff signatures. This meant the provider could not demonstrate from records whether medicines had been administered as prescribed on those occasions. One person kept medicines at their bedside without a medicines care plan, risk assessment or documented monitoring. Staff confirmed there were "No checks in place to determine whether additional doses had been taken."

Prescribed thickener powder used to reduce the risk of aspiration was not stored securely. Some "as required" medicines did not have detailed protocols to guide staff on when medicines should be administered and what alternative actions should be considered before administration. We also found expired items in first aid kits. These were removed following our feedback, but replacement stock had not been provided by our third visit.

However, we observed a medicines round that was calm and organised. Nurses checked medicines against records, explained medicines to people and recorded administration appropriately. Only staff who had received training and competency assessments administered medicines.