Ellesmere 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 good. At this assessment the rating has remained good.

This meant people were safe and protected from avoidable harm.

This service scored 62 (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.

There were systems in place to investigate when things went wrong to identify improvements or ways to prevent incidents reoccurring. This meant people were protected from avoidable harm.

Records of staff meetings showed that incidents were discussed with staff so learning could be shared.

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 to the home. People and their relatives consistently told us that they were involved in this process.

Where it was identified that people required additional support the provider developed plans of care with health care professionals to ensure they received that support.

Feedback from healthcare partners was positive, one professional told us, “I have always found them open to learning and they work well with us to address complex issues that arise with the residents in their care.”

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.

People told us they felt safe living at the home. One person said, “The staff are lovely here, I feel safe and protected.”

The provider had policies and procedures in place to protect people and reported concerns to relevant agencies in a timely manner.

Staff received training about how to recognise abuse and what to do if they thought it was occurring. Conversations with staff showed this learning had been embedded in their working practise.

When restrictions were made on people’s liberties, the management team ensured Deprivation of Liberties Safeguards (DoLS) authorisations were sought when needed and any conditions imposed by them were followed.

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.

People and their families told us that they were consulted about their safety. One relative told us, “I feel that the home are very good at consulting us and asking for our input in to how they should be cared for.”

Risk assessments were completed which identified the level of risk and provided guidance for staff on how to support people safely.

When people’s needs changed, people and their families told us they were involved in reviews.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider had recently been issued an enforcement notice from the Fire and Rescue Service and was in the process of making the required improvements to the environment. Feedback from the Fire and Rescue Service was that they were satisfied with the progress made and had extended the timescale to complete the work.

The décor at the home was in poor condition and in need of refurbishment. People and their relatives commented on this but consistently told us that this did not impact on the quality of the care they received. One person said, “I recently moved here from a home which had a much nicer environment, but I didn’t get the standard of care I receive here.”

The registered manager showed us an action plan for improvements and refurbishments to the home which they had agreed with the provider. However, they were waiting for the remedial work relating to fire safety to be completed before commencing this.

In communal areas such as bathrooms we found products that if misused could be hazardous to people’s health and these should be kept behind a locked door when not in use. The registered manager took immediate action and removed these items.

People were not protected from the risk of crush injuries. Heavy items of furniture such as wardrobes had not been anchored to the wall. We shared concerns with management who took immediate action to secure the wardrobes.

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.

People and their families told us there are enough staff to support them. One person told us, “If I want help, I never have to wait long for staff to come.”

Recruitment procedures at the home required strengthening. Providers application form asked candidates for 15 years of employment history. By law the employer should obtain a full employment history and an explanation for any gaps in the history. The provider carried out Disclosure and Barring Service (DBS) checks prior to staff commencing at the service. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Staff told us they felt supported by management at the home and records showed they received regular supervisions from management.

Staff told us they received adequate training to carryout their role and records supported this.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

People and relatives told us the home was always clean and free from malodours. One family member said, “This was one of the first things we noticed. The home smelt clean.”

We found some equipment and surfaces had not been maintained to a standard where effective cleaning and disinfection could take place. For example, the varnish on some handrails and tables had worn away.

The home had an infection control policy and we observed staff wearing the correct personal protective equipment during our visit.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We found tins of prescribed drink thickener in 2 communal areas. If ingested this could cause suffocation. We shared concerns with management at the home who took immediate action to install lockable cupboards for them to be stored in by drinks stations.

We found all other medicines and treatments were safe and met people’s needs, capacities and preferences. People received their medicines safely and as prescribed. Medicines were stored safely including those which required additional security checks. Staff received training and had their competency assessed. Any errors were documented and appropriate action taken to mitigate the risk of reoccurrence. People’s support needs for their medicines were recorded in their care plans. We observed a medicine round and saw people’s preferences were known and respected. Medicine Administration Records (MAR) were completed appropriately. Regular medicines audits were carried out so any errors would be quickly identified, however, these required strengthening as they had not identified the concerns with the drinks thickener.