Easterlea

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• 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

We found 2 breaches of the legal Regulations. The provider no longer had systems and processes in place for the safe use of medicines and people had not always been safeguarded from abuse. Overall, risks were assessed and planned for. Safety related events were not consistently used as an opportunity to put things right, learn and improve. However, there were enough staff to meet people’s needs and the premises and equipment were kept clean and hygienic.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were not able to comment on the safety culture within the service, but relatives told us managers and staff were approachable and receptive and that they were encouraged to raise any concerns and felt listened to. Comments included, “Yes it would be absolutely easy to do that, [raise concerns] they are approachable” and “When I talk to them, they're very receptive… if [Family member] says anything to the carers they tell [Registered manager], and she goes and talks to them.”

Overall, staff told us they were encouraged to raise concerns and confirmed they were listened to. As an example 1 staff member told us a concern they raised had been “Looked into and resolved and an apology provided”. Another staff member told us about raising concerns about staffing being short at weekends. They said, “They were receptive, they acted quickly in putting extra staff in place.” The majority of staff confirmed when safety related events or near misses happened, there was an opportunity for learning from these with a ‘no blame’ focus. For example 1 staff member told us when they reported an error, the registered manager had, “Reported to the relevant authorities, all staff were made aware…. Registered manager completed an incident form, and it was used to learn from.” A second staff member said following incidents, the leadership team might “Explain this is a better way of approaching the care / incident whatever it might be. They will let you know you can learn and put new ways of working in practice. It is accepted everyone is on a learning curve.” One member of staff told us they did not believe there was a culture of safety which was based on openness and honesty. They shared an example where they did not feel medicines related incidents had been fully investigated or responded to in an open and transparent way. Our findings corroborated these concerns. The provider and the registered manager were aware of these issues and had scheduled meetings with the relevant staff. The deputy manager told us staff team meetings were held twice a year, and extra meetings would be arranged to discuss any specific matters, such as CQC inspections for example. They said assessments of people’s needs and any risks or safeguarding issues were reviewed each month. The deputy manager told us they or senior care staff did regular reviews with people to encourage feedback or raise any concerns, needs or suggestions for improvements.

The systems in place to report and investigate concerns or incidents and accidents needed to be more robust. Whilst there was some evidence remedial actions were taken to prevent reoccurrence of falls for example, it was not always clear whether people’s care plans were updated to reflect these risk management approaches. Overall, incident forms were not consistently completed in sufficient detail and there was a lack of evidence that robust investigations always took place to establish potential root causes of safety related incidents. We were not assured safety related events were consistently used as an opportunity to put things right, learn and improve. Incidents and accidents were individually reviewed but there was no evidence that these were reviewed to look for themes and trends that might result in changes that could improve care for others.

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.

People were not able to comment on whether the safeguarding systems within the service helped them to feel safe, but their relatives were confident their family members were safe and protected from harm. Comments included, “Yes totally [safe]… She says they are very kind to her”, “Oh yes definitely [Safe] because she has people around and if she needs any help they are there. The staff are lovely” and “If [Family member] had any concerns she would tell me. So far there hasn’t been any.”

Staff told us they had training on how to recognise and report abuse. One staff member told us, “If a resident is acting out of the norm, acting more scared, or more agitated, you can tell they are not their normal self, you could look for changes in their behaviour which could suggest abuse” and another said, “For example, bruising that can’t be explained, if they haven’t had a fall, this could be the way staff are handling them and I would report straight to the manager”. Overall, staff were confident any concerns brought to the attention of the registered manager would be acted upon. Comments included, “From my experience, [Registered manager] is very approachable and takes any incident seriously…. It is all about the individual, that they feel safe and secure” and “Definitely they would take it seriously.” One staff member was not confident all safeguarding concerns were acted upon correctly by the leadership team and felt there had been a delay in the escalation of the concern to external agencies. Our findings corroborated this as we identified a safeguarding incident had not being escalated to relevant agencies in a timely manner. We spoke with the registered manager about this, they acknowledged they should have made the alert earlier and would do so moving forward.

We observed staff supporting people in a non-restrictive way. People were free to come and go about the home as they pleased. We saw a person who was known to be at risk of falling, wanted to stand up. A member of staff saw this and went to support them, asking what it was the person wanted to do and walking with them. This was in line with the person’s care plan and risk assessment.

Processes did not support a robust and thorough response to safeguarding concerns. We identified that a safeguarding allegation had not been managed correctly or escalated and reported to the local safeguarding adults’ team or to the Care Quality Commission in a timely way. We were only notified of this concern when an external service reported this as a safeguarding concern. There was a lack of evidence safeguarding concerns or alerts were used to promote learning opportunities to keep people safe. Whilst the registered manager maintained a log of safeguarding issues it was not clear how this was being used to ensure lessons were learnt and to embed good practices. Following the assessment the registered manager told us of the learning they had taken from this review of the services processes in relation to safeguarding people from harm. The provider had a safeguarding policy, but this was not detailed enough to provide guidance for staff and leaders and on their role and responsibilities in relation to safeguarding people from harm. More robust systems were needed to assess and document mental capacity assessments. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The registered manager told us no-one currently living in the home was subject to any restrictions, were free to leave and not subject to continuous supervision. They had not therefore needed to apply for any DoLS.

Relatives told us the culture within the service supported people to express their choices and make decisions about their care. This included when to get up, what to eat and how to spend their time. Relatives overall felt involved in their family member’s care. Most described this as a process which took place when their family member first moved to the home, and which now was more informal through regular discussions with staff or the registered manager as needs changed. Comments included, “[Family member] wasn’t involved too much but we were totally involved.” We went through things when we first went to the home”, “Its most excellent, there have been no formal meetings, but the conversations are fairly regular and I’ve been kept informed” and “Yes we know we can feed anything in if we need to, I have not looked at the plan in a while but yes [I feel involved]”. Relatives also told us staff were good at responding to people in a sensitive and supportive manner when their family member was distressed. One relative said, “They are very good at reassuring her” and another said, “Yes whilst they are very efficient and professional, they are also very loving with the residents.”

Staff confirmed they had access to people’s care plans and risk assessments via the provider’s digital social care record system. Two staff felt the care plans and risk assessments could be improved upon and updated more often, but also described informal processes for sharing information which they felt mitigated any shortfall in the care plans. For example, 1 staff member said, “Staff are hands on every day, we talk about the changing needs of residents, we are let know if people are not walking so far as they used to be… It’s a small team and a small home so it is easier to keep up.” Staff gave an example of how they mitigated risk. One person was at increased risk of falling due to changes in their health. A sensor alarm had been fitted in the person’s bedroom to alert staff when they got up. Staff told us this was not to restrict the person but to help prevent falls and ensure a member of staff was on hand. If the person wanted to get up, for example to go to the bathroom or just for a walk, a member of staff would walk with them. Staff also told us that should they identify a person was developing vulnerable skin, they would put measures in place such as an air mattress to prevent any further decline. Staff said they felt confident responding in a positive way to people’s distress or agitation. A member of staff told us, “A resident who is new has packed her case ready to go home and says her daughter is collecting her when this is not the case. You have to sit with them and talk to them, make a cup of tea …try to make them feel as settled and as comfortable as possible.” The deputy manager said risk assessments and accident/incidents were reviewed, and they or senior care staff did regular service user reviews to encourage feedback and to enable any concerns to be raised.

We observed staff supporting people safely. No concerns were identified with the safety of staff practices during our assessment. When a person displayed distressed behaviours, we observed staff were able to calm them using humour, and through speaking clearly as the person had a hearing impairment.

People's care plans and risk assessments were not always sufficiently personalised or lacked detail. This included guidance on how staff should respond to distressed behaviours. This meant there was a risk staff may not know how to support people safely. Some risks had not been adequately planned or mitigated. For example, 1 person was prescribed a medicine which increased their risk of complications should they fall but this had not been considered as part of their falls risk assessment. Following a number of falls, including those where there were minor head or other injuries, we were not assured staff consistently followed best practice guidance or the provider’s ‘Falls Procedures Policy’ in terms of when to seek medical advice. We were concerned this could lead to a risk of staff acting outside of their scope of competence. There was no documented system in place for monitoring people following falls. The registered manager has now implemented a post falls monitoring tool. New risks were discussed during staff handovers and there was also a process of using alerts on the provider’s digital recording system to ensure staff were aware of changes in people’s needs. We saw these being used in practice. There was some evidence people’s capacity to consent had been considered as part of the care planning process, but this needed to be more robust to ensure the principles of the Mental Capacity Act 2005 were being consistently followed. The registered manager had not seen/retained copies of Lasting Power of Attorney documents, this is important to ensure decisions are made by the correct people when a person lacks capacity. On a quarterly basis, a member of the leadership team would sit down with each person to ask for their feedback about their care and support. Records of these meetings needed to be more detailed as they did not fully demonstrate a holistic approach to managing risk or people’s needs in a way that was safe and met their preferences.

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

People were not able to express in any detail to us their views about the skills / number of the staff supporting them. Most relatives were positive about staffing levels and felt there were always enough staff on duty. Comments included, “Yes, there are loads of staff,” “I would say without doubt there are always enough staff. I would say the staffing levels are very good” and “I’ve never seen a situation where a staff member was needed and there wasn’t”. Two relatives felt there were times when staff were busier, and this could mean their family member had to wait longer than they would like for support at times. Relatives were confident staff were well trained and able to meet the needs of their family member. Comments included, “Yes totally [Well trained], even the junior staff are well briefed”, “I believe they are well trained yes” and “They have a policy that new staff do shadowing and when you look at how long some of the staff have worked there it can’t be a bad place to work”.

The registered manager told us staffing levels were planned to ensure people received safe care. They told us, “During busy periods, such as residents being poorly, full capacity or end of life care, we put additional staff on the rota to ensure residents needs are met safely. Monday to Friday, both, I and [Deputy manager] are available to help during busy periods on the floor, [Deputy manager] is also available on a Saturday morning… We listen to staff during reviews/supervisions, if the feedback is that additional staff are needed, we review this and add them.” Most staff felt there were usually sufficient staff on duty, and this allowed the provision of person centred care. Comments included, “In the main there are enough staff but there are occasions due to illness when there isn't enough, but this is infrequent”, “We are a busy home and staffing levels are good” and “We will try and encourage them to do what they can for themselves, we don’t get told off for taking time, some have greater needs than others and staff have the time to do this”. Some staff felt there were busy periods but explained that the provider had been responsive and added additional staff at weekends for example. Staff told us they completed an induction which most felt helped to ensure they were knowledgeable and ready to perform their role. Overall staff told us the training programme was good. Comments included, “Appropriate training is given,” “I have regular training every year, we have people coming in from companies as well as training which is online” and “It is a good training programme, we have dementia training, manual handling and I am soon going to be doing fire inspection training.” Staff told us they received supervision which most found helpful. One staff member told us the registered manager went through with them whether they had met goals or still needed to improve or needed more experience or training for a particular role.

Staff were visible and we observed staff were able to meet people's needs in a person centred way. A health care professional shared a similar observation saying, “Carers were always seen in the communal areas and appeared to quickly respond to any call bells when I would visit.”

Staff rotas were in place and showed that planned staffing levels were met. Whilst there was evidence that staffing levels were flexed according to need, or in response to feedback from staff, the provider did not have a dependency tool that was clearly based on peoples changing needs to inform staffing levels. A programme of staff training was in place. This was a mixture of online training and some training which was delivered in person by either the leadership team or an external provider. Overall, the training programme was appropriate and covered a range of relevant topics. A training matrix was maintained to ensure effective scrutiny and oversight of training compliance. Staff received support in the form of supervision. This involved 2 supervision meetings each year and 2 observations. Observations were undertaken to ensure staff were able to understand and apply their training in practice, however, the records of these could be more comprehensive, and a more detailed assessment of the competency of staff to administer medicines was also required. There were safe recruitment processes in place. This included the completion of a check with the Disclosure and Barring service and the gathering of references.

People were not able to express in any detail to us their views about the cleanliness of the home. Feedback from relatives was positive. Representative comments were, “I go there at different times and days and it's always clean smells fresh” and “I see staff cleaning, I have never seen anything that looks as if it isn’t clean.” Each of the relatives we spoke with confirmed staff wore personal protective equipment such as gloves and aprons appropriately.

Staff were confident the home was kept clean and hygienic. Comments included, “Yes generally the home is clean they have a cleaner who is only in a few days a week but cleaning is also picked up by the carers and [Registered manager] will let you know if there is a smell for example she will ask for it to be investigated and resolved” and “Yes we have a cleaner and we all have our daily chores and it is always nice and clean”. Staff all confirmed they had infection control training and were able to describe how they followed infection control procedures. This included the correct use of personal protective equipment, the safe management of laundry and regular handwashing.

We observed the home was kept clean. Staff wore personal protective equipment (PPE), such as gloves and aprons, when going to provide personal care to people in their rooms.

Whilst we did not identify any specific concerns with cleanliness or infection control, no infection control audits were undertaken by the leadership team to identify risks and monitor quality. This was not in keeping with the provider’s policy which stated, “An audit programme is in place to ensure appropriate policies have been developed and implemented.” Cleaning staff were employed for 20 hours a week. Cleaning schedules and records were in place and fully completed to show what tasks had been done.

Relatives were confident their family members were being supported to take their medicines safely and most felt they were involved, when necessary, in decisions relating to medicines. No concerns were raised with how medicines were being administered. One relative told us, “I would be [Involved] if there was something that needed to be different, but the doctor and [registered manager] lead on that” and another relative said, “Yes, they always talk to us, always [About medicines decisions].” Relatives were confident their family member was supported to manage their pain effectively. For example, 1 relative said that staff always checked whether their family member had any pain, and another shared that staff were good at identifying if their family member was in pain and offering pain relief as needed.

We received mixed feedback from staff about the safety of medicines within the service. One staff member raised concerns to us about the safety of some of the medicines practices within the service. Some of their concerns were corroborated by our own findings. Other staff raised no concerns. They described a good relationship with the GP and pharmacy and were able to describe the processes they followed to administer medicines and the records they kept in response. They were also able to appropriately describe the actions they would take should they make a medicines error. Two staff did raise concerns about the electronic medicines administration record (eMAR) which they felt was not always straightforward to use, didn’t meet the needs of the service and lacked functionality. Concerns were also raised that communication of medicines related information and learning was infrequent. We discussed this with the deputy manager who told us the eMAR system was being removed and paper records were to be maintained instead.

Prior to the assessment, there had been a number of concerns raised with the Care Quality Commission about the management of medicines within the service. Our assessment found that some of these concerns were still happening. Medicines training had expired for some members of staff and a refresher not undertaken in line with the providers policy. Medicines competency assessments whilst undertaken lacked detail. The provider had medicines related policies in place. However, these were not comprehensive enough to ensure the safe use and management of medicines. Whilst staff were able to describe the actions, they would take in the event of a making an error, we were not assured all medicines incidents were recorded and appropriately investigated. Medicines were not reconciled according to national recommendations when people moved into the service, posing a risk people might be administered medicines at the wrong dose or administered medicines that they were no longer prescribed. The eMAR being used by the provider did not offer appropriate safety mechanisms or provide leaders with oversight as to the use of medicines within the service. Access to the eMAR was not always restricted to trained staff. We were not assured the person recorded as administering medicines, was the person that had administered them. Regular checks of medicines and audits were not in place to identify issues. Care planning, including information for ‘when required’ (PRN) medicines was not person centred and lacked detail. Records of prescriber’s instructions were not being retained and medicines were not always administered as the prescriber intended. For example, 1 person prescribed a twice daily dose of pain relief, was on 7 days given this medicine 3 times a day and on 3 days received this 4 times a day. Medicines were being pre-dispensed by the night staff for the day staff to administer the following morning. This is not safe or good practice.