Edenmore Nursing 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.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good.

This meant people were safe and protected from avoidable harm.

This service scored 75 (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.

Staff were able to explain how they would respond to an incident where someone may have suffered an injury. They explained the actions they would take at the time which included completing appropriate documentation and escalating to senior staff.

The provider understood their responsibilities under Duty of Candour and relatives confirmed they were kept informed of any 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.

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 correct information would go with them.

The 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. There were provider level systems that ensured data shared and requested by the local authority was captured.

Staff were able to clearly describe to us how they would identify potential abuse and what action they would take to escalate this appropriately. One staff member told us, “If I had any safeguarding concerns or witnessed any abuse, I would raise it initially to [registered manager].”

Relatives were positive about the safety within the service. One relative said, “Staff are amazingly kind. Much more than I expected. They treat him so well. I see how they work with him and other residents. So much patience. He feels safe there.”

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 provider had appropriate systems and processes in place. There was a tracker that showed where DoLS had been approved and others that were pending with the relevant local authority.

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.

Care plans were detailed with information for staff on how to avoid potential triggers in relation to known risks, for example behavioural triggers. Care plans detailed how staff should recognise and support people. This personalised information demonstrated people were at the centre of risk management.

Incidents were analysed monthly by the registered manager and provider to ensure necessary actions had been taken to mitigate against risk. There was also a ‘Page of the Day’ document that provided staff with key care and treatment information on known risks.

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

Equipment such as lifts, hoists and those related to fire and gas safety had been inspected in line with requirements. Each month safety checks were completed on equipment used to support people, such as specialist beds, call bell systems, wheelchairs and walking aids.

Personal evacuation plans were in place. These had been regularly reviewed to reflect people’s support needs in the event of needing to evacuate the building in an emergency. Staff told us they had received fire training in person and on-line and records supported this.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff told us they worked together well to provide safe care that met people’s individual needs, and our observations supported this.

The service determined their staffing levels based on occupancy and needs. Staff told us there was sufficient staff on duty to meet people’s needs. Relatives did not raise any concerns around the staffing levels and were complimentary about the staff and the care they provided. One relative told us, “The staff are exemplary in what they do. Dad seems very happy.”

The provider had appropriate induction, training and continual staff support in place. Staff were very positive about their training which was provided at the service and in the provider’s head office. One staff member said, “The training is very good and we also have the corporate training in Bristol and these days have been very helpful.”

Staff were recruited safely with appropriate checks taking place, they took part in a comprehensive induction and training programme to ensure they were competent and had the right skills to provide safe care.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

The environment was clean and generally smelt fresh; housekeeping staff were on duty. The registered manager and provider used systems and processes to monitor the completion of cleaning tasks by staff.

Staff were trained in infection prevention and control. Staff understood when and why they should use personal protective equipment (PPE) and 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 provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people and their relatives in planning where appropriate, including when changes happened.

Medicines were stored, administered, recorded and disposed of safely. Robust processes were in place to ensure people received their medicines in line with their prescriptions. Regular stock balance checks were carried out.

Some people were prescribed additional medicines on a ‘when required’ basis. The PRN protocols we looked at were personalised and informed staff of key information such as variable dosage and maximum daily dosage when using these medicines. Medicines that required additional storage measures were stored correctly, and stock balances were accurate.

Staff implemented and followed best practice guidance, for example, they ensured the relevant professionals and people’s advocates were involved in discussions surrounding covert administration. Relevant staff completed training in medicines and there were systems to complete continual competency assessments.