Enbridge House Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The provider’s governance systems were not effective and did not identify the shortfalls we found during this assessment. This included the concerns outlined in the Safe key question of this assessment in respect of medicines, risk management, safety of the equipment and premises, infection prevention and control and recruitment process. A failure to operate effective governance systems was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We reviewed audits for staff training records which evidenced staff had not all completed the training relevant to their role. We also noted leaders were responsible for delivering some staff training and carrying out competency assessments for staff handling medicines. However, leaders did not always follow good practice guidance or adhere to the providers medicines policy and national guidance. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found multiple examples where people’s care records had missing information, were incomplete or did not reflect the care they received. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We received positive feedback from staff that they felt supported in their role. The leaders of the service were visible and staff could access advice and support. We received positive feedback from professionals that leaders of the service built good relationships with professionals and people who used the service.

This service scored 50 (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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The providers have run the home for many years. As an independent provider, they do not have access to the same level of support, guidance and resources potentially available to a larger provider. For example, they have not had any external health and safety consultancy to advise and guide them in ensuring they meet their legal requirements. We noted as a small leadership team there were a lot of duties for leaders to fulfil. However, there was not a clear demarcation of roles within the leadership team to ensure it was always clear who was responsible for overseeing and managing delegated tasks in the service.

The deputy manager told us they were well supported in their role by the providers, and they had opportunities for development. We received positive feedback from professionals that leaders communicated well. Staff told us they felt supported in their role and leaders were available.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Quality assurance and governance systems in place were not effective or robust. Audits completed did not identify the concerns we found at this inspection and leaders responsible did not always have the required knowledge to ensure effective oversight or drive improvement. For example, health and safety audits completed on 03-01-24 failed to identify any of the environmental safety issues we found during this assessment and did not drive improvements. This included continued concerns from the last report in respect of water temperature, legionnaire's disease and TMV's. The provider did not demonstrate they had undertaken the actions they had committed to, therefore, we were not assured the governance processes were effective at identifying and addressing potential health and safety risks to people using the service. We found audits to review safety events at the service were not always accurate or completed. We found examples where safety incidents involving fractures were not included on the log we were shown to enable effective overarching oversight and analysis. Systems to ensure staff were sufficiently trained and competent in their role were not fully effective. We identified multiple examples where people’s care records had missing information or contained contradictory information. Therefore, the providers review process was not effective at ensuring care plans contained all the information required to deliver care to each service user safely.

Leaders told us they felt that the systems and processes in place were adequate. Tasks were delegated between the leadership team and each had lead responsibilities they undertook responsibility for oversight of.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.