Eskdale House Supported Living Service

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 newly registered 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 safe care and treatment. The service did not always ensure people’s risks were recorded where required. The service did not always ensure incidents were managed effectively. Medicines were not always managed safely.

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 service did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

There was a system to record and investigate incidents. However, we found this was not always effective. For example, we found 1 staff-reported incident remained in draft, long after it occurred. It had not been escalated to management to instigate an investigation.This meant the incident had not been investigated and did not lead to any actions or learning. It also meant incidents could not be audited effectively.

Where incidents had been investigated and lessons learned, these had been shared with the staff team.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Westmorland and Furness Council had recently acquired the service from the previous provider. The registered manager told us essential pre-placement information had not been transferred by the predecessor, meaning this data was unavailable for review during the inspection.

The new provider had established processes to manage the transition between services. However, these were not always effective. We identified care plans did not consistently include up-to-date information regarding people’s current needs and risks. This meant there was a risk people would not receive seamless care delivery should they be referred into another service or go to hospital.

The service did not always work well with people to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

There was a system to investigate safeguarding incidents and share them with the relevant authorities, where required. However, we found this was not always effective. For example, we found while 1 incident had been investigated and the service told us safeguards had been put in place, this was not evident in the alleged victim’s support plan. This meant there was a risk the person would receive inconsistent support to safeguard themselves.

While the service followed the Cumbria Safeguarding Board’s safeguarding policy, this was not service specific.

Where a Court of Protection Deprivation of Liberty (COPDOL) had been applied for, we saw evidence the service had updated the court with additional restrictions, where this was required.

We received mostly positive feedback from people and their relatives about how much safer they felt since Westmorland and Furness Council took over the management of the service. One relative told us, “I feel they are safe now, although weekends are still a bit of a worry.”

The service 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.

Where 1 person had a high level of need around their mobility, their mobility care plan and risk assessment did not include any information or guidance about how staff should support them with this.

Where 1 person was being supported around healthy relationships, behaviours and eating and drinking, their care plans and risk assessments lacked detailed information or guidance about how staff should support them with this. This meant the provider could not be assured people were receiving consistent and effective support around their risks. This also meant the provider could not be assured it was monitoring people’s outcomes effectively.

While people had personal emergency evacuation plans (PEEP), these were not always effective. For example, some lacked information about people’s risks or how people could be safely evacuated. This meant the provider could not be assured people could be evacuated safely in the event of an emergency.

The service had not fully considered the risks associated with unknown individuals accessing the premises. Following feedback from the inspection team about this, the registered manager put a plan in place to assess these risks.

The service did not always detect and control potential risks in the care environment.

Some risk assessments, associated with the premises such as fire safety and legionella, were the responsibility of the landlord. However, we found the service had not sought assurances from the landlord where their fire and legionella risk assessments had shown several actions required immediate resolution. Following feedback from the inspection team about this, the registered manager showed us evidence they had since approached the landlord for assurances.

The service could not evidence that all staff, where required, had received mandatory training for fire safety.

We informed the local fire safety branch about the concerns we found on inspection.

However, we found examples of effective processes in place such as safe water checks, portable appliance testing (PAT) and general maintenance of people’s flats.

The service 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.

The service could not evidence how they had determined how many staff were required to meet people’s needs. Where people required 1-1 or 2-1 support to access community activities, the service did not know whether they were receiving the correct amount of support. One relative told us, “People are not getting their allocated hours and there is slow progress regarding staff training.” This meant people were at risk of not having full control or choice over their lives or accessing things which were of importance and interest to them. Following feedback from the inspection team about this, the service put a plan in place to review people’s staff support needs with their social workers.

The service could not evidence all staff had received their mandatory training. The registered manager told us this was due to the previous provider not transferring this information to them when they took over. The service did not have a formal action plan to address how all staff would receive their required training. This meant the provider could not be assured people were being supported by safe and effective staff.

However, we received some feedback from health and social care professionals, who had provided staff with training, that they had engaged well with this.

The service was actively recruiting staff and had put in place senior support staff and supervisors to improve the practice of support staff. One relative told us, “There are more experienced staff now who know [person] really well.”

The service followed safe recruitment procedures.

Team meetings, one-to-one meetings and daily handovers were in place to support staff to provide safe care to people.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Procedures to manage the risk of infection were mostly effective. Infection control and prevention checks were carried out regularly and issues were dealt with where required.

People and their relatives told us there had been a lot of improvement in the cleanliness of people’s flats. One person told us, “Staff support me to clean and tidy my flat.” One relative told us, “We have seen improvements, [person] is clean, their personal care has improved significantly, and their flat is much cleaner.”

Staff were provided with personal protective equipment (PPE) and we observed them wearing and removing this appropriately. One staff member told us, “I have had training regarding hand hygiene and about how to use PPE.”

However, we found some food items in 1 person’s fridge had passed their used by dates. We found no evidence the person had come to harm because of this. Following feedback from the inspection team, the service put a plan in place to address this.

The service 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.

Where people were given ‘as required’ medication, staff did not always follow the protocol for administering this medication. For example, staff did not record what non-medication strategies had been attempted, the person’s symptoms or the outcome of giving the medication. This meant the provider could not be assured people were being given their medication appropriately.

Where people were prescribed creams, risk assessments were not always in place, where required. For example, we found 1 person’s steroid cream, stored in their flat, was not labelled correctly and there was no associated risk assessment for this cream. This meant the provider could not be assured medicines were always effective or that people’s risks had been considered.

Care plans did not always include up to date, consistent and personalised information about people’s medicines support. For example, 1 person’s care plan stated they self-administered their medication. However, we found staff gave them their medication as they did not understand what the medications were for or why they were taking them. This meant the provider could not be assured people’s medication needs had been assessed effectively.

The service kept people’s medicines in locked boxes in the office; however, the room temperature was not being recorded which went against its medicines policy. This meant the provider could not be assured medicines were being stored safely or that they were effective.

Audits of medicines practices were not being carried out. This meant the provider could not be assured it could identify and act on medicines issues when required.