Eastfield

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People did not always receive safe care and support. People’s health needs were not always managed safely, for example in relation to skin integrity, distressed behaviour or diabetes. We found that medicines management was not always safe or effective and people did not always have the medication they were prescribed. We found 3 breaches of the legal regulations in relation to safe care and treatment, safeguarding, and staffing.

This service scored 34 (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 always protected from the risk of harm. For example, one person was checked at 6.30am and staff noted they were asleep. When staff next checked on the person at 8am, they had become disorientated and were found in a storage cupboard where they sustained a small injury. The incident record stated that ‘increased checks’ would be implemented to protect the person from a similar incident. There was no information about how frequent the checks should be completed, or how this was shared with staff. We reviewed the person’s daily notes and found no checks on the person were completed following the incident.

Staff had not consistently ensured people received safe care and treatment following incidents. For example, one person had an unwitnessed fall in their room. Incident records state that staff should have completed post fall observations, however these had not been fully completed. The registered manager had not identified this has not been completed. Another person fell, and the incident record stated they sustained a head injury. There was no information on the incident form to confirm what action staff or the registered manager had taken to ensure the person was safe and received the medical attention they needed. The providers electronic care system created a ‘post falls observations’ document which should have been completed by staff but was not.

Incident management was not consistently effective to identify any lessons to be learnt. We identified incidents that had not been reviewed by senior leaders or the management team to determine if any action needed to be taken. Staff had completed ‘behaviour’ forms for 3 separate incidents, which had not been escalated for review. The deputy and registered manager had also not picked up three additional incidents during their audits and therefore they had not been reviewed. Staff had recorded a person had attempted to self-harm. The registered manager was unaware of this incident but felt it was not an incident of self harm. Another incident recorded by staff was an incident where one person had pushed another. The registered manager was unaware of either incident. We were not assured that incidents were being reviewed by the registered manager, were well managed and appropriate action was taken.

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 protected from the risk of constipation. People who were at risk of constipation did not have constipation risk assessments in place. Records showed that 1 person did not open their bowels for up to 11 days on 4 separate occasions. Another person had 3 episodes where their bowels did not open for up to 9 days. On these occasions medicine was not given to people, and staff failed to seek medical advice for people to prevent them becoming unwell with constipation. Other risks were not mitigated. For example, one person lived with diabetes. Their care plan was not clear on what actions staff should take if they were concerned the person’s blood sugar levels were too high, and different actions to take should their blood sugar levels be too low.

Staff did not have a good knowledge around managing risks to people. Some people had specific health needs which could put them at risk. For example, one staff member told us one person had no health needs, however this was not the case. This person had a diagnosis of epilepsy along with other health needs. Another staff member was unaware that a different person had a diagnosis of epilepsy. Staff’s lack of knowledge of people’s health needs placed them at risk of receiving inappropriate care and treatment. Some people were at risk of skin breakdown. Two people were prescribed and needed barrier creams to help keep their skin intact. Staff told us these creams were in place and being used. However, when we asked staff to show us the creams were in place, for one person we found there was no cream in place, and for the other person we found that the cream had run out. Staff failed to identify and report this to the registered manager. The registered manager failed to identify this was not in place or being used by staff.

There was not an effective system to identify and mitigate risks to people. Guidance to support people with complex health needs including pressure/wound care, constipation, safe moving and handling of people, or distressed behaviour were not always in place or sufficiently detailed to inform staff how to support people safely. Some people could become distressed or agitated. Care plans were not sufficiently detailed to inform staff how best to support people and how to reduce distress to them. For example, an incident report we reviewed detailed that one person became disorientated and distressed. It stated that ‘multiple staff’ were involved in the incident, but was not clear on the role staff took, or any learning from the incident. There was no evidence that the incident had been reviewed by the registered manager, or that de-briefs with staff were completed. Following the incident the person’s care plan had not been updated.

The service was not always well maintained and safe for people. Several areas of the service, including corridors and bedrooms had exposed nails on the walls, which could present a risk to people. One person had a broken light above their bed, which presented a risk as there were electric wires exposed. The external case as broken, exposing sharp edges, which were in easy reach. On the first floor of the service there was an exposed wire on the floor which could present a trip hazard for people. The sink in one person’s room was hanging off the wall and presented a significant risk. We reported this to the registered manager, who organised for the sink to be fixed, however this issue had not been reported by staff. An empty room was being used to store equipment including a hoist, wheel chairs and standing aids. The room was unlocked and the volume of equipment stored in the room could present a falls risk to anyone who could become disorientated and find themselves in the unlocked room.

There were not always effective systems in place to identify the significant environmental concerns identified during the assessment. Although there was a maintenance log, staff did not always report issues to the registered manager or add them to the maintenance log. The registered manager had not ensured that processes were in place to ensure that items within people’s rooms had been tested and were safe to use. Some people had portable heaters within their rooms. These had not been risk assessed, and there had been no consideration of risks for people who could become disorientated. One person had a fridge in their room; however staff had not reviewed items in the fridge, or risk assessed this. We identified food within the fridge which had passed their expiry date, however it had not been removed and posed a risk it could make the person unwell if consumed.

While the people we spoke to expressed that they were generally happy with their care, our assessment found care did not meet the expected standards. For example, staff lacked the skills and experience to support people living with dementia in a positive way.

Staff did not have the skills, knowledge and competence to support people in line with their support plans. Staff we spoke with lacked knowledge on how to support people living with dementia in a positive way. For example, one staff member told us, “I learnt from dementia training how to handle someone with dementia, if in funny mood always know where the exit is.” Another staff member told us, “I don’t think so (training in dementia care).” Staff did not always feel there were sufficient numbers of staff on duty. One staff member told us, “It can be a bit chaotic here because people’s needs change. It can get a bit challenging at times. I think there could be a bit more staff. 1 more care staff would be beneficial.” Another staff member told us, “Sometimes enough staff, sometime not. Would be good more staff. Busy in morning. Sometimes easy, sometimes difficult.”

While the people we spoke to expressed that they were generally happy with their care, our assessment found care did not meet the expected standards. People did not live in a clean and hygienic environment. One person had faeces on their bedding. Another person had faeces on their bed frame. This had not been identified and cleaned by staff. One person’s room had a chair which was highly stained and smelt of urine.

There was no soap in the clinical room and we did not observe staff washing their hands. We were not assured staff were following good hand hygiene practice in line with current guidance. Staff had not identified and reported areas of the service which were in poor state of repair, and therefore not able to be cleaned. Care staff, including kitchen staff had not reported areas of the home which were not clean. For example, the kitchen floor was not clean and had a visible build up of dirt on the floor. Whilst there were two domestic staff deployed each day, we were not assured that they were deployed effectively or that they had the skills to complete their tasks.

Parts of the service were not clean and in good condition. The toilet on the first floor had no working taps to enable people to wash their hands after using the toilet. We reported this to the registered manager, and they organised for the taps to be fixed. The toilets on the ground floor were in a poor condition, the toilets were highly odorous and there was liquid on the floor.

Effective processes were not in place to ensure that people lived in a clean and hygienic environment. Parts of the service were in a poor state of repair and exposed people to risk, as they could not be cleaned effectively. For example, skirting boards and walls were visibly dirty where liquids had been spilt on them. Walls in some people’s rooms were heavily stained. These had not been identified and addressed by the registered manager.

People did not always receive their medicines safely, and as prescribed. In one person’s bedroom we found 2 halves of a tablet. Staff had not identified this, and it was not clear who the tablet belonged to, or when someone could have missed their medicine. Care plans in place for people were not sufficiently detailed to inform staff how best to support them. One person had epilepsy; their care plan did not detail what kind of seizures they experienced, or that they were prescribed rescue medicine to be administered in the event of a seizure. Within another care plan there was some information about the rescue medicine but it was not clear what dosage should be administered. We could not be assured people would receive time sensitive medicines such as paracetamol at the correct time due to medicines rounds taking a long time and times of administration not being recorded. This meant they might have experienced avoidable symptoms of their medical condition, including pain.

The registered manager told us they completed regular audits. However, audits had not identified most of the concerns we found on the assessment. Where an action had been recorded on a previous audit, for example, recording the date opened of a medicated cream, we found staff were still making the same error. We observed that people’s creams were stored in their rooms. The registered manager confirmed this was not risk assessed, despite telling us that some people could become disorientated and sometimes were found in other people’s rooms. The temperature of people’s rooms was not checked or recorded to ensure that creams were kept at a suitable temperature in line with the manufacturer’s guidelines. We found that people’s prescribed creams were in other people’s rooms, on one occasion the prescribed creams of someone who was no longer at the service were being used by another person.

Systems to ensure that people received their medicines safely were ineffective. Two people did not have the required prescribed creams in stock to enable staff to apply them and keep their skin healthy. Staff did not know where to request the cream to be replaced and staff had not reported that the two people did not have their prescribed cream in place. One person had a prescribed toothpaste in their room, which was dispensed in October 2023, which had been opened but barely used. Staff had not dated when this was opened. Creams and ointments were not dated when they were opened which posed a risk that staff could be administering creams and ointments that had passed their expiry date. Systems to ensure that people who were administered medicine to reduce distress were not well managed. One person was administered ‘as and when’ medicine on 3 occasions. Staff did not document why they administered the medicine, or if it had the required effect. The registered manager failed to review the administration of the medicine. The medicine was administered at similar times on all 3 dates. Before administering the medicine staff did not detail what alternative steps they took to try to reduce the person’s distress. Daily records for those 3 dates documented the person was ‘unsettled’ or agitated on 1 occasion before administering the medicine. Staff were not always following guidance for administering controlled drugs. Processes for completing medicines administration records were either not in place or not being followed correctly to ensure medicines were administered safely. For example, staff were not recording where on the body they were putting medicated patches. We could not be assured staff were following manufacturers site rotation instructions to avoid skin irritation. We could not be assured people were receiving their medicines safely.