Estherene 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.

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.

At our last assessment, the service was in breach of legal regulation in relation to staffing and safe care and treatment. At this assessment, improvements had been made and the service was no longer in breach of regulation.

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.

Falls, incidents and accidents were analysed and measures in place to reduce further incidents, such as referrals to other professionals and updating people’s care plans and risk assessments. Lessons learned were shared with staff to ensure they were aware of how to support people to reduce risks.

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.

People’s needs were assessed prior to moving into the service with the input of the person and their representatives, including other professionals involved in their care. Visits to people in their home, hospital or other care service were undertaken. This supported the management team to find out about the person, assess if their needs could be met and plan the transition into the service.

Relatives told us how they had visited the service prior to their family member moving in, if the person was unable to visit themselves. A person’s relative told us how the staff supported their family member to transition smoothly when they moved in, “The team have been brilliant, particularly when [family member] first moved in… As [family member] has adjusted [family member] is as relaxed as [they were] at home.”

Where people required to be admitted to another service, such as hospital, important information was shared to ensure health professionals were aware of how the person’s needs were met.

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.

Safeguarding policies and procedures were in place. Staff received training in safeguarding and information was accessible on how to report concerns, such as to the local authority safeguarding team.

Since our last assessment, people using the service had been consulted about the use of gates to their bedrooms, which reduced the risks of other people entering their personal space uninvited. Some people had chosen to have these in place and were happy with them.

Where people were required to have their liberty restricted due the risks and lacking capacity to make their own decisions, applications were made to the local authority to ensure any restrictions were lawful. These were kept under review.

People told us they felt safe in the service, this was confirmed by relatives who felt their family members were safe. A person’s relative told us, “No worries about the care and my [family member] at all, in fact they are marvellous.”

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.

Improvements had been made in how the risks to people were assessed and guidance provided to staff in how to mitigate risks. This included risks associated with falls, choking, skin integrity, constipation and diabetes.

Where people were at risk of falls, equipment was in place, which alerted staff if people were trying to mobilise independently. In addition, the service was using electronic equipment which alerted staff to sounds, and activity at night, which would require checks to be made.

People’s topical medicines, such as creams, were now stored in lockable cabinets in their bedrooms, to reduce the risks of them being accessed and ingested by people.

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

Risk assessments were in place for the stairs in the service and the risks of people falling down the stairs were being mitigated.

Records showed risks in the environment were assessed and checks were undertaken to ensure the environment was safe. This included checks on fire safety, equipment used, window restrictors and the risks of legionella bacteria in the water system. Servicing of equipment was undertaken as required, this included hoists.

The registered manager told us a new fire system was being installed in October 2026, for which risk assessments were being completed. The registered manager told us how they planned increased checks on people and the environment whilst the work was being done.

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.

Since our last assessment, improvements had been made in the staffing arrangements in the service to reduce the risks of people not having their needs met in a timely way. Staffing levels, sickness and call bell response times were monitored. Where required, agency staff could be used, and bank staff had recently been employed, if existing care staff could not cover. Staff said shifts were generally covered, although the team had experienced pressure during a recent infection outbreak.

People and relatives told us the staff were available when needed. A person’s relative said, “There are plenty of staff on duty, so there is no concern for safety there.”

Staff were receiving the training they needed to meet people’s needs and were provided with one to one supervision meetings, to provide a forum to receive feedback, raise any concerns and identify training needs. Training to staff was provided in face to face and eLearning.

Records showed staff were being recruited safely.

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.

The service was visibly clean throughout and there were no malodours. A person’s relative told us, “I have no concerns for the cleanliness in the home.” Following our first inspection visit there had been an infection outbreak, the management team had taken the appropriate action to report and increased the cleaning regime to reduce spreading. A person told us how they felt the management and actions of staff during the outbreak was positive, “Staff are second to none, they went over and above, caring of us, pulled all the stops out, cleaning, caring for us.” A person’s relative said the service was, “Wonderful and clean.”

Staff received training in infection control and prevention, and they had access to personal protective equipment (PPE). We observed staff wearing PPE appropriately during our visits.

Some staff were infection control champions, and the registered manager told us they attended local authority infection control meetings and an infection control conference to keep up to date with requirements.

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

There were safe systems in place to store, dispose of, order and administer medicines as required. Regular audits supported the management team to identify and address any shortfalls promptly. However, we noted gaps in the paper records for documenting when people’s topical medicines had been administered. The management team checked these with the electronic records and found people had been supported with their creams. They also took action to advise staff in the importance of completing both records, introduced a system for the daily checking of these medicines and were in the process of communicating with the GP to ask for more information of the administration of the medicines, such as if they were to be used as required (PRN).

A person’s relative told us their family member could sometimes refuse their medicines, they were kept up to date, staff had acted and they were told when the person’s GP had been spoken with regarding their medicines.

A person had a change in the medicines they received, administered by a district nurse. The care plan had been amended in some parts, it was not updated throughout and still showed in some parts they received insulin. The person was receiving appropriate medicines, so the impact of the outdated information was low. Once we pointed this out, immediate action was taken by the management team to ensure the care plan was updated throughout.

Staff responsible for supporting people with their medicines had received training and their competency checked. Staff who were supporting people with their topical medicines, such as creams, had been trained to do so safely and their competency was also checked.