Archived: Ermington 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 remained Requires Improvement. We identified an ongoing breach of the Safe care and treatment regulation and a further breach in the Premises and equipment regulation.

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.

This service scored 50 (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. Lessons were not always learnt to continually identify and embed good practice.

The provider maintained a record of any falls or adverse incidents reported by staff within the service. This analysis identified patterns and trends so action could be taken to prevent recurrence of events such as falls. However, we identified safety issues had not been identified, or action taken to reduce the risk. This included some people’s call bells not being within reach, and an unlocked rooms containing hazardous items that could cause people harm.

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.

There was a procedure for staff to follow before people were admitted to the home. This included a pre-admission assessment to establish a person’s needs. The provider undertook this in collaboration with the relevant funding authority, where appropriate. Care records showed where healthcare partners had been involved in people’s care and treatment to improve outcomes.

The provider confirmed they had a process in place to ensure continuity of care. For example, if a person was admitted into hospital, key information from their care records the hospital staff may need went with them.

The provider worked with people and healthcare partners when safeguarding matters were identified. Staff explained how they wanted to ensure people were safe within the service. The provider shared concerns with relevant organisations appropriately. There were provider level systems that ensured data shared and requested by the local authority was captured.

There were systems to ensure people were protected from the risk of harm, abuse or discrimination. The provider worked with safeguarding agencies where required and relevant information was shared. The provider had raised concerns with the local authority where safeguarding concerns had been identified. The service was currently subject to a number of safeguarding investigations led by the local safeguarding team.

Staff were able to clearly describe to us how they would identify potential abuse and what action they would take to escalate this appropriately. No concerns were raised by people or their relatives about the care and support they received from staff.

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

The provider did not always work well with people to understand and manage risks. It was not clear that staff had always provided care in line with people's assessed needs to keep them safe from avoidable harm.

Where people had specific health needs which placed them at risk of harm, risk assessments had been completed and the risks relating to the condition had been considered. However, we were not assured people at risk of or recovering from pressure ulcers had been repositioned in-line with their assessed need. We identified examples within some people’s repositioning records where care had notbeen recorded as being delivered. This placed people at risk of unsafe care, and this contributed to a breach of the safe care and treatment regulation.

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.

Equipment such as lifts, hoists and those related to gas safety had been inspected and serviced in line with requirements. However, we found significant shortfalls in the environment relating to maintenance and safety. Some areas of the service required significant maintenance. For example, we identified poorly maintained ad unclean mobility equipment including commodes and walking aids that were currently being used by people. There were large cracks on walls, damaged carpets, electrical sockets detaching from the wall and holes in radiator covers. This presented a safety risk to people living at the service and others.

Areas of the service environment were unsafe. Toilets and bathrooms that had been deemed as unsafe and out of order were still accessible, placing people and others at risk. We identified an unlocked bedroom not being used to which some people using the service had access. Within the room there were a number of trip hazards. Additionally, there were hazardous chemicals and a water bottle containing an unknown liquid that had mould or fungus on the top. The service supported people living with dementia and there was a risk they could consume these products. This placed people at risk and contributed to a breach of the safe care and treatment regulation and the premises and equipment regulation.

The provider told us there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, wereceived feedback from people, their relatives, staff and professionals that the service needed more staff to ensure people’s needs were consistently met.

People, their relatives and staff told us there was not always enough staff on duty to meet people’s needs. Rotas were planned in advance, and the provider told us they were determined on occupancy levels and people’s needs. Whilst our observations on the day indicated people’s needs were met, the feedback we received raised concerns. A staff member commented, “There are times when we are extremely short staffed and recently this feels like it is most weeks.” All of the people who lived at the service commented on how consistently busy staff were. One person told us, “It’s changed for the worst. There always used to be more staff. There’s not enough now. Sometimes I haven’t been up till 1pm.” This information was communicated to the provider during feedback for them to take action as needed.

When staff started work at the service, they completed a period of induction. The interim manager explained the new package they had produced for new starters. The induction included a period of shadowing where they worked with more senior staff to understand the day-to-day running of the home and meet with people whom they would be supporting.

The provider had appropriate training and continual staff support in place. Staff were generally positive about their training and told us they received ongoing individual and group supervision together with an appraisal. Some staff commented positively on recent specific training they had received in relation to oral hygiene and skin integrity. We saw records evidencing staff training.

Staff were recruited safely with appropriate checks taking place to ensure their eligibility to work and suitability to work with vulnerable adults.

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.

The environment was not consistently clean, and the assessment team identified there were certain areas of the service that smelt of urine. Concerns were raised by people, relatives and staff about the cleanliness of the service. The laundry area of the service required significant refurbishment.We identified concerns in people’s bedrooms which included a toilet blocked with faecal matter, which had attracted flies in the bathroom, and dirty flooring in bathrooms. Staff told us there was a rodent issue in the basement section of the service where there were bedrooms and showed us an unoccupied bedroom where they said there was rodent droppings on the window area. We did not observe any rodents and could not confirm the substance on the windowsill, however it had the appearance of rodent droppings.”This presented an infection control risk but also contributed to a reduction in people’s quality of life. This contributed to a breach of the safe care and treatment regulation.

Staff received training in infection prevention and control. Staff understood when and why they should use Personal Protective Equipment (PPE) and we saw this was readily available throughout the building.

The provider 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.

At our last assessment, the provider did not have effective systems and processes to manage medicines safely and was in breach of this part of the safe care and treatment regulation. At this assessment, we found the provider was no longer in breach of this part of the regulation, but improvements could still be made.

Medicines were mostly stored, administered, recorded and disposed of safely. 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 and had relevant protocols in place. However, we identified one person had run out of a specific medication and this had not been identified. Additionally, medicines provided by a dietician for 1 person had been incorrectly entered onto the person’s medicine records. On checking the stock balances of some medicines, we found a case where the physical balance did not match the recorded number. Medicines that required additional storage measures were stored correctly, and stock balances were accurate.