Emily Jackson 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

People were protected from the risks of abuse discrimination and harm by staff who understood how to keep people safe. Risks to people’s health, safety and well-being were assessed, managed, and reviewed. There were enough skilled, experienced, and knowledgeable staff and they were recruited safely.

This service scored 75 (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.

People told us they felt safe living at Emily Jackson House. Their comments included, “I feel very safe with staff. I do not know what I would do without them” and, “I do feel safe, fortunately I can do a lot for myself, if I didn’t feel safe, I would talk to the staff or manager about it.”

The manager and regional director told us that there were no open safeguarding alerts currently. Staff we spoke with were able to demonstrate knowledge of the different types of abuse people may be exposed to and what actions would be taken to address these and keep people safe. The regional director completed a monthly visit where they ask staff about the safeguarding policies and procedures, they have not identified any shortfalls in staff knowledge since completing these. We were told that all staff have completed mandatory safeguarding training and, annual refresher training when applicable. We were told that all safeguarding alerts, concerns and or accidents/incidents are completed on the providers clinical governance system. These were reviewed by the manager, regional director and the provider’s clinical governance lead nurse to identify themes or trends to avoid risk of reoccurrence. Staff had completed safeguarding training. They knew the various form of abuse, the signs to recognise them and actions to take. They told us they trusted the registered manager to take actions to protect people. Staff knew how to whistle blow if needed. Staff understood the principles of the Mental Capacity Act and Deprivation of Liberty Safeguards. They explained that people were not restricted in anyway and no form of physical restraint was used in the home.

We observed people were comfortable with staff. Staff were respectful and polite towards people. They treated people with dignity. Staff respected people’s personal space. They allowed people to walk about freely and to do the things they want to do. We observed staff doing one to one observation on a person. They walked with the person but did not invade their space or stand too close.

There were safeguarding policies and procedures in place to ensure any safety concerns were investigated and, when necessary, action taken to keep people safe. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. 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 MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found the service had completed applications for people where required and appropriate legal authorisations were in place to deprive a person of their liberty. Any conditions related to DoLS authorisations were being met. Records showed the service had made appropriate safeguarding alerts to the local authority when necessary.

Care plans and risk assessments provided guidance for staff about how to keep people safe. People told us staff supported them to remain safe. They told us, “I do feel safe, I have everything exactly where I want and the staff know not to alter anything” and, “Everything I need is in here. I just use a walking frame at present.” A relative commented, “I am involved with decisions. There are periodic reviews and so far, no big decisions have had to be made.”

The manager and regional director told us that all people living in the service had up to date risk assessments. These detailed the risks people faced whilst receiving their support. These were updated and reviewed regularly and reviewed when changes in a person’s needs had been identified. Each person was reviewed on a regular basis in the ‘daily stand up’ meetings where a person was reviewed by all heads of department, including nurses, care staff, maintenance and chefs. Any issues identified during these meetings was shared and action taken to address any concerns. Staff told us they discussed risks associated with people’s care and activities and tasks they undertook to support them. For example, before they performed moving and handling tasks, they explained to people what they planned to do and the procedures involved. They told us it reassured people and helped them cooperate in the activity. Staff told us they informed people’s relatives if there were changes in their situations.

On 2 different occasions we observed staff support people transfer and mobilise. Staff explained to the people what they wanted to do and communicated the procedure involved. They gave people time to follow the instructions given. They used the correct equipment assessed for the people. They completed the tasks carefully.

Risks to people’s health, safety and well-being were managed, monitored, and reviewed. Action was taken to keep people as safe as possible. Changes in people’s needs were discussed and care plans and risk assessments updated to ensure staff were able to access up to date information. The provider used recognised tools to help assess people’s health care needs. For example, the Malnutrition Universal Screening Tool was used to assess for any nutritional risks and Waterlow to assess risks of pressure sore development. When people were at risk of developing pressure areas, specialist equipment, such as air-wave mattresses and pressure relieving cushions, were used.

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 spoke positively about the staffing levels. They said, “It is tricky because they are always busy but everything gets done and no one rushes me so perhaps there are enough and that is weekends and nights too” and, “Staff are quick and if it is a little thing they will do it immediately and a bigger one might need another carer to help and then you wait a little” A relative commented, “I think there are enough, they work very hard but if someone needs help they are very quick to respond.”

Staff told us they felt there were enough staff to ensure people were safe and received support with their assessed needs. The service had a large team of bank staff available to work and cover shifts when required to ensure continuity for people. We were told by the manager that agency staff were no longer used as there were enough staff employed by the service to complete the care people required. There were vacancies for a few positions but this did not have an impact on the service delivery. One staff member told us, “We have enough staff on duty. We always do.” another staff member said, “There are 5 care staff on shift today on each floor. The number of occupied rooms and the needs of the residents determine the number of staff on duty. Some residents have 1 to 1, agency staff cover the 1 to 1s so it doesn’t affect staffing levels. The number of staff is enough. We get on well with the job.”

We observed that there were adequate number of staff around to support people safely. The nursing staff and care staff were hands on and supported people promptly with their needs. Staff had time to sit and chat with people. People were not left unsupervised in the communal areas. Call bells were answered quickly. Staff showed they understood their job roles and carried them out with confidence and commitment. They told us they were properly supported in their roles. One staff member told us, “We get supervision quarterly. I find it very helpful. They have been supportive.”

There were systems in place, such as the use of a dependency tool, to ensure there were enough suitably qualified, skilled and experienced staff on each shift. Staff were recruited safely. Recruitment policies and processes helped ensure applicant were treated equally and there were no disadvantages based on any specific protected equality characteristic. Checks included references from previous employers and Disclosure and Barring Service checks which provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Staff completed regular training and their competencies were checked on topics, such as moving and handling and medicines management, to ensure staff continued to follow best practice. Staff met with their line manager for regular 1 to 1 supervision, where they had the opportunity to discuss their personal development.

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

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