We carried out a review of the data available to us about Etheldred House Care Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Etheldred House Care Home, you can give feedback on this service.
We found the following examples of good practice.
The designated setting was a separate building within the location’s grounds. On admission, people who have tested positive for COVID-19 would be admitted using the front entrance to the building to enter and exit. Staff will use a separate side entrance and exit to the building.
Each person’s single occupancy room had on-suite facilities such as a shower, toilet and sink. There were nine bedrooms in total. The communal bathrooms had been closed to reduce the risk of cross contamination.
The registered manager confirmed that there would be a dedicated team of staff including care workers and housekeeping staff who would only work at the designated setting Butterfly House.
Staff had additional infection prevention and control training from the CCG (clinical commissioning group) in house around COVID-19, handwashing and how to put on and remove their PPE safely. Staff also had CCG ‘response’ training which trained staff to help them identify COVID-19 symptoms and to guide them on where to seek advice.
Team leaders undertook competency checks and spot checks on staff such as handwashing.
The furnishings in people’s rooms within Butterfly House were wipe cleanable. Fabric canvas and artwork were to be removed and replaced with pictures that had a wipe clean front. There was separate bedding, crockery, glasses and equipment to be used in the designated setting only and not shared throughout the location. This was to reduce the risk of cross contamination.
The registered manager told us that if staff at the designated setting had to evacuate in an emergency, they would assemble in a separate area to staff working in the main building. They said they had updated their locations fire risk assessment to reflect this.
We were assured that this service met good infection prevention and control guidelines as a designated care setting.
Further information is in the detailed findings below.
This unannounced inspection took place on 17 August 2017. At the last comprehensive inspection on 4 June 2015 the service was rated ‘Good’. At this inspection we found overall the service was ‘Good’.
There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People were kept safe and staff were knowledgeable about reporting any incident of harm. People were looked after by enough staff to support them with their individual needs. Pre-employment checks were completed on staff before they were assessed to be suitable to look after people who used the service. People were looked after by staff who were trained and supported to do their job
People were helped to take their medicines by staff who were trained and had been assessed to be competent to administer medicines.
People were supported to eat and drink sufficient amounts of food and drink. They were also supported to access health care services and their individual health and nutritional needs were met.
The registered manager was aware of what they were required to do should any person lack mental capacity. People’s mental capacity was assessed and care was provided in their best interests. Staff were trained and knowledgeable about the application of the MCA.
People were treated by kind, respectful staff who enabled them to make choices about how they wanted to live. People and their relatives were given opportunities to be involved on a day-to-day basis about their planned care.
There was a strong commitment to developing respectful, trusting relationships. Staff all demonstrated care, compassion and empathy towards the people they supported. Staff used creative ways to engage people with the service. People and their relatives were extremely satisfied with the service they received and told us the service provided an excellent level of care and support. People and relatives consistently told us they/their family member felt cared for, valued and listened to and that their views mattered. The ethos of the service was to make people feel valued, supported and included, with an aim to enhance quality of life. Visitors to the service, including children were welcomed by staff members and were encouraged to visit. Interactions promoted wellbeing and showed staff knew people well. People were at the heart of care.
Comprehensive care plans were in place detailing how people wished to be supported. These had been produced jointly with people living in the service, their relatives and staff. People had agreed what care and support they needed and were fully involved and engaged by staff in making decisions about their support. People were able to choose how they spent their time and what individual and/or group activities they participated with. People participated in a range of activities within the service or in the community and received the support they needed to help them to do this.
People were involved in the running of the service. Regular meetings were held for people who lived at the service so that they could discuss any issues or make recommendations for improvements. People were offered a chance to raise any other business that they wanted to. People confirmed that they were asked for their views on the service and could make recommendations for improvements if needed.
There was a process in place so that people’s concerns and complaints were listened to and were acted upon.
There were clear management arrangements in place. Staff, people and their relatives were able to make suggestions and actions were taken as a result. Quality monitoring procedures were in place and action was taken where improvements were identified.
Etheldred House Care Centre provides nursing and personal care for up to 82 people, some of whom are living with dementia. The home is divided into four “houses” that are called strawberry house, pear house, apple house and cherry house. All bedrooms have en-suite bathrooms and there are external and internal communal areas for people and their visitors to use.
The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Our last inspection took place on 12 November 2014 when we found the provider was meeting all the regulations we looked at.
This unannounced inspection took place on 4 June 2015.
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Staff were only employed after the provider carried out satisfactory pre-employment checks. Staff were trained and were very well supported by their managers. There were sufficient staff to meet people’s assessed needs. Systems were in place to meet people’s needs effectively and safely. Staff were aware of the procedures for reporting concerns and were proactive in protecting people from harm.
People’s health, care and nutritional needs were effectively met. People were provided with a varied, balanced diet and staff were aware of people’s dietary needs. Staff referred people appropriately to healthcare professionals. They accepted and followed advice and guidance from other professionals. People received their prescribed medicines appropriately and medicines were stored in a safe way.
The CQC monitors the operations of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) which applies to care services. We found people’s rights to make decisions about their care were respected. Where people were assessed as not having the mental capacity to make decisions, they had been supported in the decision making process. DoLS applications were in progress and had been submitted to the authorising body.
People received care and support from staff who were kind, caring and respectful. Staff respected people’s privacy and dignity. People, their relatives, staff and other professionals were encouraged to express their views on the service provided.
People and relatives were encouraged to provide feedback on the service in various ways both formally and informally. People, and their relatives, were involved in their care assessments and reviews. Care records were detailed and provided staff with specific and detailed guidance to provide consistent care to each person that met their individual needs. Changes to people’s care was kept under review to ensure the change was effective. Staff supported people to take part in hobbies, interests and activities of daily living. There was a varied programme of group and one to one activities available to people.
The registered manager was supported by senior staff, including qualified nurses, care workers and ancillary staff. People, relatives and staff told us the home was very well run and that staff in all positions, including the registered manager, were approachable. People’s views were listened to and acted on.
The registered manager continually sought to improve the service provided. The service demonstrated excellence by achieving nationally recognised accreditation for providing care for people who live with dementia.
This is a summary of what we found;
Is the service safe?
When we arrived at the service the staff member who let us in asked to see our identification and asked us to sign in the visitor's book. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.
People told us they felt safe living in the service and that they would speak with the staff if they had concerns.
We saw that the staff were provided with training in safeguarding vulnerable adults from abuse, Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS), which were updated every year. This meant that staff were provided with the information that they needed to ensure that people were safeguarded.
People were provided with an environment which was clean and tidy .We undertook a general tour of the entire service, which included communal areas and bedrooms and bathrooms on both floors. We randomly checked the condition of furniture and mattresses in eight people's rooms and found all to be of a good standard and in a clean condition. We saw that chemical cleaning products were stored safely and that staff had had training in infection control. We also saw evidence of protective equipment being available to staff and used when required.
We saw records which showed that the health and safety in the service was regularly checked. This included regular fire safety checks, this meant that people were protected in the event of a fire.
Is the service effective?
People told us that they felt that they were provided with a service that met their needs. One person said, "They are very professional, and always talk to me about what they are doing." Another person said, " The staff treat me properly and they seem very well trained." Another person said, "I am very happy here."
We looked at how care was planned and delivered. People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. Each care plan we looked at contained detail about how staff should care for the person. This means staff had adequate information to care for people physically but also to care for their wellbeing.
Is the service caring?
We saw that the staff interacted with people living in the service in a caring, respectful and professional manner. People told us that the staff treated them with respect. One person said, "I get on well with all of them." Another person said, "They are all very kind and they work so hard." People who spoke to us were positive about the service. One person told us, " I think all the staff here are wonderful. They are really caring and treat you like a person, not a number."
Is the service responsive?
People using the service were provided with the opportunity to participate in activities which interested them. People's choices were taken in to account and listened to. People told us that they knew how to make a complaint if they were unhappy. People's care records showed that where concerns about their wellbeing had been identified the staff had taken appropriate action to ensure that people were provided with the support they needed. This included seeking support and guidance from health care professionals, including a doctor and district nurse as well as regular input from a nutritionist, a speech and language therapist and a dietician.
Is the service well-led?
The service worked well with other agencies and services to make sure people received their care in a joined up way. We saw evidence of regular quality assurance monitoring in all key areas of the service's performance. The manager produced a monthly overall audit of the home which was sent to the regional manager. This showed us that there were effective quality assurance systems in place to assess and monitor the quality of the service that was provided to people. As a result the quality of the service was continuingly improving.
Relatives we spoke with told us that they were very satisfied with the quality of care their family member received. One relative we spoke with said: 'It is a lovely home. I can go home feeling confident that Mum is being looked after well'.
We observed staff supporting people in a kind and calm way. Staff spoke respectfully to people. People told us they felt safe and knew who to contact if they wished to raise any concerns about their care.
Care and support was appropriately assessed and reviewed to meet people's needs.
There were effective recruitment procedures in place which ensured that people were cared for by suitably qualified staff. There was an induction and mandatory training programme for new staff to ensure they were competent to deliver care.
The organisation had effective audit systems in place to monitor the quality of care and ensure that the service people received was safe and effective.
We observed staff supporting people in a kind and calm manner. Communication was positive and staff spoke respectfully with people. Staff told us they very much enjoyed working at the home and felt well supported and are offered lots of training to carry out their roles in supporting people to meet their health and care needs.
The organisation had good systems in place to monitor the quality of the service provided and action had been taken to address any issues that were highlighted as needing improvement.
We received many positive comments from people's relatives including, 'I can't fault the place, staff are respectful and helpful' and 'I am particularly impressed with the staff on Apple unit: their efficiency and knowledge are good'. Relatives appreciated that staff kept them very well informed with any events affecting their family member. One relative stated, 'Staff phone me straight away if dad needs to see the GP or anything, they're really good like that'. Several relatives told us how useful the relatives' meetings were, and in particular the speakers who were invited to give presentations. Two people reported that the talk from a solicitor about wills and power of attorney was useful and another commented; 'The relatives' meeting about dementia really opened my eyes and made me understand dad's behaviour a lot more'.
A GP who knows the home well told us that the care offered there was good, and in particular the end of life care people received. Another health care professional, who works closely with the home to place people who need continuing care following their discharge from hospital, told us, 'It's my favourite home, the manager there is brilliant and really switched on'. She was particularly impressed by the support staff gave to people and their relatives.
All the evidence we received from people using the service, their relatives and visiting health care professional clearly demonstrated that this was a well run home where people received high quality care, provided by skilled and caring staff.