Edwardian 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. At our last assessment we rated this key question good. At this assessment the rating has changed to 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.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not have effective safeguarding systems in place to help protect people from the risk of abuse.

A safeguarding alert was raised with the local authority because of some of the feedback we received from relatives.

Safeguarding concerns were not always identified or notified to the appropriate organisations. This meant some incidents which required a safeguarding notification, for example, alleged physical abuse, had not always been investigated or steps taken to mitigate future risk.

Safeguarding records lacked the detail required to ensure people were protected from abuse.

However, staff had received safeguarding training and understood how to recognise abuse and report concerns.

The provider did not always effectively manage risks and meet people’s needs safely.

There were gaps in assessments in areas such as supporting people with emotional distress, self-neglect and promoting their wellbeing. Records indicated that people were not always encouraged to mobilise when they needed to.

Care plans and risk assessments did not always contain the information staff required to ensure all risks were managed. For example, a risk assessment relating to physical aggression did not provide strategies to help guide staff on how to deliver safe care and support.

However, the service had a positive approach to risk taking. The registered manager said, “We arranged for one of our service users to travel abroad. The registered manager involved several health and social care professionals to ensure the person’s medication could still be managed by their family whilst they were away.”

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

We found concerns with the safety of the home environment that had not been identified prior to our inspection. The quality of people’s mattresses and pressure cushions were not being routinely checked. We found several discarded items laying around the car park on our 1st visit. We identified safety risks such as an air conditioning unit not fully secured to the side of the building, a risk of people being burnt from a heated towel rail, a broken extractor fan, a radiator that was no longer secured to the walls, windows and a door being in a poor state of repair, chipped tiles in a shower room and a rusty appliance in a person’s bedroom.

Several areas of flooring required replacement and were hazardous due to being uneven. We identified trip and falls risks from trailing wires around the home. Communal areas had damaged seating. A blow heater was being used in the cabin in the garden, contradicting the provider’s policy not to use these.

Systems and processes to ensure the safety of the premises were not effective. The registered manager did not have oversight of the schedule of works for the care home. National guidance had not always been followed to promote the safety of people living at the service. For example, the lift had not been inspected within the specified interval for regular thorough examinations. Health and safety audits were taken place every month, but these did not identify the concerns we found during our assessment.

The provider did not always make sure there were enough qualified, skilled, and experienced staff.

The registered manager had not ensured safe recruitment practices were always followed, gaps in staff work history had not always been explored, and an employment reference had not been verified. The provider addressed these concerns in response to our findings.

The staff we spoke with did not always feel there were enough staff deployed. Records showed the provider had not deployed enough staff as per their safe staffing level assessments. This meant there was an increased risk of people’s needs not being met.

Although most staff had completed their mandatory training. Staff had not always received the training they needed to give them the skills they required to effectively meet the needs of people living at the service. For example, in areas such as Parkinson’s, end of life, learning disabilities, autism and positive behaviour support.

The provider did not always assess or manage the risk of infection effectively. For example, the general waste was overflowing in the designated outdoor area. The clinical waste bin was not secured and remained unlocked until our follow up visit despite us informing the registered manager. Good infection control practices were not being followed, such as rubbish bins with no pedals, ensuring hand soap and sanitiser dispensers were not empty and using fly screens fitted in the kitchen.

We identified areas that had not been kept clean, such as the external cabin, a build-up of mould on a person’s bedroom window. We observed unclean safety mats and personal items such as razors, rusty scissors, hairbrushes, and a wet flannel being left in communal bathrooms.

This increased the risk of infection not being prevented and controlled.

However, staff could describe scenarios when they were required to use personal protective equipment (PPE).

People received their medicines as prescribed. The service had some systems and processes in place to enable the safe and effective use of medicines. Audits and incidents had identified some areas for improvement, and we saw learning from these being implemented and followed by staff. However, there were no fire risk assessments in place for people who smoked and were using paraffin-based skin products. There were also risk assessments missing for people prescribed anticoagulant medicines which increased the risk of bleeding and bruising.

Records were not in place for the application of a newly prescribed medicinal patch. This meant staff were not able to accurately record where the patch had been placed on the body to avoid skin irritation and to ensure the previous patch was recorded as removed. Staff told us, and we observed they were trained and competent to administer medicines. Where people were prescribed ‘when required’ (PRN) medicines for managing distress and agitation, PRN protocols lacked detail. Staff were aware of what could be a trigger for people and how to de-escalate without the need for medicines, this information was recorded in the care plan but was not included in PRN protocols. Where people were prescribed variable doses of a PRN medicine there was no guidance about when to use the lower dose and when to use the higher dose. Where people were prescribed the antipsychotic medicine clozapine, care plans did not contain enough detail to ensure the staff were aware of the risks and side effects to monitor for and when to escalate if there were any concerns.

The service supported people to receive their medicines safely away from the service either on leave or during holidays. They did this by working alongside district nurses to upskill people and their families in aspects of medicines administration where needed. The service worked with local services including community mental health and primary care services to ensure people received regular medicines reviews and medicines support. This included ensuring that routine physical health checks were completed.