Emmanuel House 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 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 premises and equipment.

This service scored 56 (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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider did not consistently demonstrate a positive learning culture where concerns, incidents and risks always resulted in improvement. Safeguarding incidents identified within service records had not always been submitted to CQC, and management systems had not consistently monitored safeguarding concerns alongside notification requirements. Staff demonstrated an understanding of accident reporting and incident management processes, and care records showed learning from falls through reviews, referrals and updated risk assessments. However, inspectors found limited evidence that wider learning from identified concerns, environmental risks and audit findings had been embedded consistently across the service.

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.

Systems were in place to identify and respond to risks, with detailed care records covering falls, mobility and behavioural support needs. Care records demonstrated referrals to appropriate health professionals, including falls teams, mental health services and social workers when risks increased. Risk assessments were regularly updated following incidents and people received ongoing monitoring and review where required.

The provider did not always share concerns appropriately.

People were not always fully protected from the risk of abuse because safeguarding systems and oversight were inconsistent. Records showed safeguarding concerns had occurred, including incidents of person-on-person harm and allegations resulting in injury, but some safeguarding events had not been reflected within CQC notification records. Staff spoken with demonstrated an understanding of safeguarding responsibilities and new staff described safeguarding being discussed during recruitment and induction. However, provider oversight had not consistently ensured safeguarding concerns, notifications and follow-up actions were effectively monitored together.

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.

People were involved in managing risks through personalised care planning, regular reviews and discussions with relatives and external professionals. Care plans contained individual guidance on supporting people safely while maintaining choice, including mobility, falls prevention, behaviour support and nutrition. Staff demonstrated a good understanding of balancing risk with people’s rights and independence.

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 environment was not consistently safe and presented avoidable risks to people. Inspectors observed a worn and poorly maintained environment with dirty shower chairs, dirty sluice and shower areas, peeling paintwork, damaged chair upholstery, missing wall tiles and unlocked personal protective equipment (PPE) storage. A fire exit was partially obstructed by wheelchairs and hot water temperatures exceeded recommended safe levels. Although fire drills took place regularly, the provider had not ensured simulated fire evacuations took place. People were unable to choose where they sat and spent their time because there were insufficient suitable chairs available to meet their needs. Although routine checks were completed, these issues had not been identified or effectively addressed through oversight processes, placing people at risk. The service also relied on relatives to support some environmental improvements within the home, for example, in tidying up the courtyard garden.

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.

There were not always enough suitably deployed staff to meet people's needs safely. On the day we visited staffing pressures were evident due to sickness absence, vacancies and difficulties recruiting to key roles. Relatives, people using the service and staff consistently raised concerns regarding staffing levels, delays in support and reduced staff visibility in communal areas. The registered manager explained staff sickness was often an issue and at those times struggled to find replacement cover. One relative said, “It's like this frequently,” when commenting on staff shortages in communal areas. This limited people’s ability to move freely throughout all areas of the home. Despite these concerns, staff demonstrated knowledge of people’s needs, safeguarding responsibilities and accident reporting procedures.

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.

Infection prevention and control (IPC) arrangements were not consistently effective. A recent external IPC audit had identified a number of environmental concerns and these findings had been escalated to the provider who had generated an action plan. However, during our assessment we continued to identify hygiene and environmental concerns, demonstrating that identified risks had not always been effectively addressed and improvements had not been consistently completed and sustained.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines management processes were organised and supported people to receive their medicines safely. Medicines were stored securely, stock balances were checked, and staff demonstrated safe administration practices and knowledge of the medicines they were administering. Protocols for the safe administration of medicines prescribed on an ‘as and when’ basis (PRN) were available and care records included clear guidance for these medicines.