Eastbourne 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 inspection under the previous provider, we rated this key question good. Following this assessment, the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of 4 legal regulations in relation to how safeguarding concerns, people’s medicines and risks were managed, the lack of an effective system to ensure staff were sufficiently competent and skilled and a failure to consistently identify and share lessons learnt.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

An effective system was not fully in place to ensure lessons learned were identified and shared with staff.

We received concerns from 3 people about the culture and practices of several night staff.

We found lessons learned in relation to accidents and incidents, safeguarding allegations and complaints had not always been identified, analysed and shared.

Due to the concerns identified during the assessment, the provider agreed to put a voluntary suspension on admissions to the home to allow improvements to be made and embedded to ensure people’s safety.

An effective safeguarding system was not in place. During the assessment we identified concerns relating to people’s care and support. Not all safeguarding allegations had been raised to the appropriate agencies.

We raised a number of safeguarding referrals regarding medicines management.

Urine and blood samples had not always been obtained and sent promptly for analysis. This had led to a delay in 1 person receiving treatment for a urine infection.

Staff described restrictive practices which they used to support a person when they were resistive to personal care. We asked the manager to refer this to the local authority safeguarding team for investigation.

3 people raised concerns about the practices and attitude of certain night staff. Management were already aware of some of these concerns but they had not been appropriately escalated. We asked the manager to refer the concerns of 2 people to the local authority safeguarding team for investigation.

The home was being monitored and supported by the local authority to ensure the correct procedures were in place to keep people safe.

Risks relating to people’s care and support had not been effectively assessed, monitored or managed.

Whilst people did not raise any concerns about the management of risk, we identified shortfalls in relation to people’s specific medical conditions, medicines management, distressed behaviours and nutrition and hydration. These posed a risk to people’s health, safety and wellbeing.

Risks relating to the environment had not been fully assessed, monitored and managed.

Whilst people did not raise any concerns about the environment, we identified shortfalls in relation to fire safety. People’s personal emergency evacuation plans were not always up to date or detailed. Records of fire drills did not demonstrate that all staff had been involved in a fire drill or evacuation. We passed our concerns to the local fire safety team.

Risks relating to water safety had not been fully assessed, monitored and managed in relation to Legionella. These shortfalls posed a risk to people’s health and safety.

People had access to a range of communal areas which were well maintained. People’s rooms were personalised.

An effective system was not in place to ensure staff were suitably trained and skilled.

Whilst people raised no concerns about staff training; we identified shortfalls with staff practices regarding medicines management, nutrition and hydration, continence care, managing distressed behaviours and record keeping. These shortfalls posed a risk to the health, safety and wellbeing of people.

The provider did not have an overview of the clinical skills of staff to ensure staff had the skills and knowledge required to meet people’s needs. The provider implemented a clinical education programme for staff to provide further training and support.

Recruitment checks were carried out before staff started to work at the home. There were sufficient staff deployed at the time of the assessment to meet people’s needs.

An effective infection control system was not fully in place.

The Legionella risk assessment identified several priority actions to ensure the safety of the water system. Records were not available to demonstrate these had been addressed. These shortfalls posed a risk to the health and safety of people and staff.

We checked medicines management and noticed that utensils used to administer medicines were not clean.

We identified shortfalls relating to infection control procedures regarding 1 person’s care.

Recurring issues regarding the cleaning of equipment and hand hygiene were identified on infection control audits. There was a lack of evidence to demonstrate what actions were being taken to address these issues.

People’s rooms and communal areas were clean and there were no lingering malodours.

People were not supported to receive their medicines safely.

1 medicine used for diabetes management was found to be in use, however, this medicine was out of date. Handwritten medicines administration records were not always countersigned for accuracy and some had incorrect information transcribed.

We could not be assured medicines were being administered as prescribed since quantities remaining did not always match with signed for administration records.

Administration of medicines such as patches, inhalers and thickeners were not always clearly recorded.

Guidance to support staff in the safe administration of medicines including those used as and when required or with a variable dose, was either not always available, not correct or not person centred.

The provider’s medicines policy was not service specific and did not have enough detail to support staff with understanding the provider’s expectations for medicines management.