OSJCT Ermine 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 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. The service was in breach of the legal regulation in relation to people’s safe care and treatment.

This service scored 59 (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 approach to safety, and actions were taken following incidents to mitigate risk. However, lessons were not always learnt to continually identify and embed good practice. Relatives told us they could raise concerns with 1 relative telling us, “Staff are really receptive to comments.” Another relative told us, “You can speak informally or formally to the manager.” However, a relative told us it was difficult to get answers to issues and to speak with staff. Staff told us they knew how important it was to be transparent and open when things had gone wrong and were able to tell us how they would report and record incidents. Staff felt confident they could raise concerns without fear of blame. However, a relative raised concerns that the provider had not always been open and transparent about incidents as they had not been aware their family member had a fall until a staff member mentioned it during conversation. There were no established procedures to reflect and learn from incidents. The provider had workbooks for staff to reflect on what went well and not so well after incidents or when people had passed away to support staff. However, these had only been used a few times and were not a consistent and embedded practice. A staff member told us they had debriefs every now and again. We found some people had multiple falls in a month, and although actions were taken to make the environment safer, there had been no reflection from staff to identify what could have been done better to minimise the risk of the same incidents happening again.

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 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. The people we spoke with told us they felt safe. We observed positive and relaxed interactions between people and staff. There were posters and information displayed on noticeboards in the home, so people and their relatives knew how to make a complaint or give feedback about the service. Staff had good knowledge of safeguarding and how to keep people safe. When asked, staff were able to give examples of safeguarding concerns and what actions they would take. Staff had good knowledge about the Mental Capacity Act (MCA) and were able to explain how they worked within the MCA in their roles. The service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. The provider had a safeguarding policy outlining procedures for identifying potential risks, how to respond appropriately to concerns and ensuring staff understood their responsibility to safeguard people from abuse.

The provider worked with some people to understand and manage risks. However, staff did not always provide care to meet people’s needs that was safe or enabling. When people communicated their needs, emotions or distress, staff supported them positively. A relative told us, “The care is good. The [staff] are really kind to [my family member]. [Staff] manage their [distress] really well. They use distraction techniques and engage [family member] in other activities.” Staff explained they had received training in how to support people when they were distressed so they used techniques such as distraction or giving people a bit of time. Risks were assessed with some people, so the control measures were proportionate, and their choices were taken into consideration. Staff told us how they supported people to take risks whilst ensuring people were involved in decisions around how risk was to be managed. However, we found that some people were not being supported in line with their care needs which had left them at risk. Some care records were confusing on how people were to be supported and staff were not always sure why measures were in place. A person’s continence care plan did not make it clear how staff were to support them. During conversations with the manager it was evident the support the person was receiving from staff did not align with the guidance in the care plan. When a staff member was asked how often they supported a person with continence, they stated during routines like mealtimes, but the person was, “Good at holding it.” We were not assured people were always receiving support that was safe and met their assessed needs.

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

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. There was mixed feedback from relatives with regards to whether there were enough staff. Some relatives told us there were enough staff and their family members were supported well. However, 1 relative told us they were concerned their family member was forgotten as they had a fall in the room and staff were not aware and did not know how long they had been on the floor. Despite some relatives who had concerns about numbers of staff, relatives were positive about the attitudes of staff with 1 relative stating, “Staff are amazing.” Another relative told us, “It is a friendly home. Staff are helpful.” We observed staff interacting and supporting people at a pace that suited the person. People and staff were relaxed and engagements we observed were positive. Staff told us they had received training which enabled them to carry out their role effectively. A staff member told us, “I am impressed with the training. It’s the third establishment I have worked in, and it tops the lot of them for training, management and support.” Although some staff told us they were happy with the staffing levels, some staff explained that due to people’s increasing or varying needs, which could change daily, they could do with more staff to ensure people received the support they needed. They explained if a person was having an off day, they may require 2 staff members to support them instead of 1. Staff were recruited through robust processes which ensured staff were suitable to work in this type of service. Records showed staff had completed training in line with their roles which was up to date. The registered manager explained several processes they used to support staff such as, ‘in the moment’ forms which could also be used to give staff positive feedback.

The provider did not assess or manage the risk of infection. We received mixed feedback from relatives regarding the cleanliness of the home, with some relatives telling us the home was clean. Other relatives told us there were malodours with one relative stating, “The home is not odour free; it smells of urine when you walk in.” There were infection prevention and control concerns observed during a walk around the building which put people and staff at risk of cross infections. For example, some commodes were rusty, and the vanity covers and backrests were worn. This meant they could not be effectively cleaned and potentially harbour bacteria. Other concerns included some pressure cushions that were seen to be unclean, and the seams were broken on the covers. This meant the cushions were not protected and could not be properly sanitised. Spoons and other equipment used for administering medicine, which inspectors were told were clean, were visibly stained and could increase the risk of cross contamination. There were some malodours around the home. There had been no consideration for people’s individual needs to ensure, where needed, floors could be easily cleaned and sanitised. This was not only unhygienic but undignified for people who occupied these rooms. Cleaning schedules were not completed correctly to show extra cleaning had been carried out when the service was in outbreak of an infectious disease in line with the provider’s policy and procedures. Although the registered manager told us that extra cleaning was carried out, the service suffered 2 further outbreaks of infectious disease within 2 months. This indicated that extra cleaning or precautions had either not been carried out or were not effective. The registered manager had not always informed the health protection team when the service had gone into outbreak.

The provider did not always make sure that medicines and treatments were managed safely.

Records did not show that people were being monitored closely when prescribed high risk medicines. For example, when asked whether regular blood monitoring was carried out for a person on a high-risk medicine, staff could not find the records and had to request the information from another professional. This meant accurate and up-to-date information about people’s medicines was not always available which would be important if a person needed to move between health and care settings.

We observed people’s prescribed nutritional supplements stored in a disused toilet. The room was not secure as it had an accessible lock on the outside and although the toilet was not used, it was an unhygienic place to store people’s prescribed supplements.

Although regular audits were carried out and records had been updated, it was found during the inspection that not all medicine counts were correct.

As required (PRN) medicines were not always recorded when used and outcomes had not been recorded to monitor the effectiveness of these medicines. However, staff were observed to be kind and caring when administering medicines and observed asking people if they required PRN medicines.

Staff involved people in managing their medicines and risk assessments were in place when people were able to manage their own medicines independently.

Staff had good knowledge of the people they supported and conditions which made them more at risk of complications. For example, when people were on medicine that thinned their blood.