Elstow Manor

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• 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

We identified 2 breaches of the legal regulations. During the assessment, we found shortfalls in the provider's systems to ensure people's health and safety were always assessed and monitored. Concerns were identified in reporting incidents and accidents, documenting bruises, managing medicines, and care planning. Relatives expressed mixed feedback about how well people were supported in managing risks. We received mixed feedback from people, relatives and staff about staffing levels. There were mixed findings in relation to infection prevention and control. However, there were systems in place to enable staff, people, and visitors to raise concerns, the provider had appropriate safeguarding policies and procedures, and the environment was safe.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Peoples’ and relatives' complaints were not always recorded or responded to promptly. For example, one person told us they had made several complaints about the quality of food they received but we found these had not been documented. However, relatives felt they were informed of significant changes such as accidents and incidents. Relatives told us meetings with them took place and gave us positive feedback on the provider's senior leaders being involved with these. A relative said, "Since we had the residents meeting with the regional lead director, things have been improving, and management seems more coherent".

In response to our findings about incidents and accidents not always being documented per the provider’s policy, the provider told us they would revise their reporting procedures to ensure prompt recording and analysis of trends. We will check for improvement at our next assessment. However, staff we spoke with were able to tell us how they should report and document incidents and accidents, and that meetings were held where learning from incidents and accidents was discussed.

Staff had not always reported incidents and accidents, such as falls in line with the provider's policies. The provider had not always reviewed recorded incidents in a timely way. This increased safety risks to people and the risk of incidents and accidents reoccurring. However, there was evidence of regular residents' meetings where people gave feedback and discussed areas such as meals, maintenance, activities and their wellbeing.

Although people’s records indicated they had received support from physiotherapists, dieticians and speech and language therapists, this information was not always clearly documented in people’s care plans. Relatives gave us mixed feedback about how well people’s health-related risks had been managed. This is covered more in the ‘Involving people to manage risks’ part of the report.

Staff were able to give us examples of when they had worked with external health professionals to meet people’s health and care needs. This included working along side professionals such as speech and language therapists, physiotherapists and community nurses.

We could not be assured people always received safe care on their care journeys. We found shortfalls in the provider's systems always being established or effective to ensure people's health and safety were always assessed and monitored. More information on these concerns and the action the provider told us they would take are covered throughout this report.

A person and their relative told us about a recent concern where a staff member had examined a person’s intimate area without consent. However, the provider reported this concern to the safeguarding team, investigated it, and wrote to the person and their relatives in line with the Duty of Candor. Another person we spoke with had concerns about others entering their room and items going missing. Overall, most people and relatives we spoke with did not raise concerns about safeguarding or feeling less than safe.

Staff we spoke with told us how and when they would report safeguarding concerns if needed. For example, we asked a staff member what they would do if they had a safeguarding concern, “If I come in and see (a staff member) harming a person, I would raise this with management straight away.” They also told us they would document it if they found people had any unexplained bruises or marks.

During the assessment, we observed a person with unexplained bruises that had not been documented by staff. We shared these concerns with the local authority safeguarding team. However, information was displayed in communal areas and staff notice boards with contact information where safeguarding concerns could be reported.

Safeguarding means protecting people's health, wellbeing and human rights, and enabling them to live free from harm, abuse and neglect. It's fundamental to high-quality health and social care. During this assessment, we found evidence that people were not always proactively safeguarded from abuse and improper treatment due to concerns in areas such as reporting incidents and accidents, documenting bruises, medicines management, and care planning. However, the provider had safeguarding policies and procedures in place and there were systems to enable staff, people and visitors to raise concerns.

We had mixed feedback from relatives about how well people were supported in managing risks. Overall, relatives felt people were well cared for but gave us examples of medical health issues that had not been well managed. For example, a relative told us, “In general, care is good,” but told us an ambulance had been called for their relative as they were being “violent”, and “it turned out [relative] had a urine infection and staff should have identified and managed the situation.” Another relative told us there had been a concern with their relative not receiving dementia medicines as staff said they did not need it but went on to say, “Apart from the medical care element, I think [relative] is quite safe, and they are very caring and kind.” Another relative told us when they recently picked up a person to take them for a cataract operation, they should not have had any food or drink but had found a half-empty jug in their room. However, not all relatives had concerns. For example, relatives also said, “They always seem to know where [relative] is, and I never have any reason to believe she is in danger; lots of love from the staff makes me feel she is safe.” And, “Yes, I go there a lot and from what I have seen and the care she is given, it makes me feel she is safe.”

A staff member told us they had been struggling to support a person due to their emotional distress and showed us that their arms had several scratches from supporting the person. They told us it could require 3 staff to support them with their personal care needs. However, the person’s care plan did not give any guidance on what role each staff member would have or how to meet the person’s needs in the least restrictive way. In response to our findings about involving people to manage risks, the provider told us they would update care plans to ensure comprehensive risk assessment and management plans with a focus on people’s needs in relation to mobility, falls, and pressure care. We will check for improvements at our next assessment.

Our observations noted in other parts of this report, such as those related to medicines management, infection control and prevention, meant improvements were needed to ensure risks were always well managed. We also observed increased risks when we visited a person in their room when they were eating. When we visited earlier in the day, their bed was set to the lowest position with a safety mat to help manage the risk of falls. However, when they ate, the bed was higher, and they were not upright. The provider’s Care and Quality lead, who was with us when we observed this, agreed this could be made safer by encouraging the person to sit in an armchair and told us they would review this.

Care plans did not always contain consistent or complete information about people’s mobility, dietary needs, health, and any support needed for emotional distress. Where people needed to be repositioned to avoid pressure damage to their skin, records showed this was not always achieved in time. Records showed people were not always supported with oral and denture care. People’s care plans were not always consistent about whether people were able to verbalise if they were feeling pain or not, increasing the risk of their pain not being managed. People prescribed blood-thinning medicines did not always have care plans that considered the increased risk associated with experiencing a fall while taking these medicines. These concerns increased risks to people’s health, safety and wellbeing.

People and relatives did not raise any concerns to us about the environment's safety. We reviewed a recent residents meeting minutes where it was documented that people found the maintenance staff member was quick and efficient in fixing any issues.

Staff did not raise any concerns about the safety of the environment. A staff member described the environment as “luxurious”.

We found a cabinet in a communal bathroom that needed to be secured to the wall to reduce the risk of falling. The provider told us they would address this. Aside from this, we found the environment to be safe, well-maintained, well-decorated and well-furnished. During our assessment, Bedfordshire Fire and Rescue Service visited following fire safety improvements they told the provider to make. All actions had been signed off, and the fire and rescue service were satisfied.

Overall, the environment was safe, and systems were in place to ensure this.

There was concern about the consistency of management due to several changes in managers. For example, relatives said, “I have concerns about the high turnover of the manager because I think consistency is important.” Another relative said, “They go through quite a few managers who have been really nice, but they don’t stay, so there must be something wrong somewhere along the line”. A person told us, “I think there have been changes in managers, which does make things difficult.” People and relatives gave us mixed responses about staffing levels. For example, a person said, “I feel very safe; carers are all there to help and are kind and polite. I think there is enough of them, maybe sometimes at the weekend there is not many; if I want to go out into the garden, I will struggle to find anybody available and I might wait a bit longer for help, but overall help is very quick to come.” However, relatives felt staff would come as soon as possible if people pressed their call bells.

Not all staff we spoke with told us they received regular supervision. In response to this feedback, the provider told us they had reviewed supervision schedules and appointed additional supervisors to promote staff receiving more consistent supervision. Staff did not always feel there were enough staff at busy times or when multiple call bells were ringing. For example, A staff member told us they felt more staff were needed, "so we can give the residents more time, sit and have lunch with them, rather than just having snippets of conversations. However, another staff member said, "We have enough staff; we do have time to speak to people. People have got enough to do, there is a wellbeing team, and sometimes the homemakers will get involved (with activities)." Following feedback from a relative's meeting, the provider had increased staffing by 1 staff member. The provider told us they would further review their staffing levels following feedback from our assessment. Overall, staff felt able to approach the manager with any concerns they had.

Not all staff interactions we observed were positive. This is covered more in the well-led part of the report. Our observations of staff interaction with people were neutral overall, with some missed opportunities by staff to positively interact with people, such as non-task-focused conversations.

We found improvements were needed to aspects of staff training. We observed that staff did not always demonstrate a good understanding of supporting people living with dementia. This is covered more in the 'Shared Direction and culture' part of the report for the key question ‘well-led’. In response to this finding, the provider told us they recognised a need for improvement in staff training concerning supporting people living with dementia. Although staff had received training to support people with their medicines, our findings showed significant concerns, which did not assure us they were always competent. Similarly, shortfalls we found in care plans did not assure us that staff had the skills needed to undertake care planning. Staff supervision records reflected what staff said about not always receiving regular supervision. However, staff were recruited safely. We found evidence that the provider had investigated and acted when there were concerns about staff practice. The provider’s dependency tool showed they were providing additional staff in relation to people’s assessed dependency needs.

Overall, people and their relatives did not raise concerns in relation to infection prevention and control. A relative said, “there has never been a problem with cleanliness.”

In response to our less positive findings, the provider told us they would take action by reviewing their infection prevention and control systems and processes. We will check for improvement at our next assessment. However, staff we spoke with did not have any concerns in relation to infection prevention and control. A staff member confirmed they had received training in infection prevention and control and told us regular spot checks were carried out, including observations of their handwashing techniques.

We observed that a person’s bedroom smelt strongly of urine and found their care plan did not provide consistent information on their support needs in this area. During our 2 visits, 7 days apart, we observed that the same 2 open juice cartons in a communal fridge were unlabelled. These cartons had a use-by date dependent on the date of opening. We also found prepackaged fruit that had ‘expired’ 1 day prior in the fridge during our first visit. We observed a person’s hearing aid storage box was dirty and contained a significant wax build-up. We observed a person’s dentures and their toothbrush handle was also in a very unclean state. Although we did observe some concerns in this area, the vast majority of the service was clean, pleasant and odour-free.

As per our observations in this part of the report and shortfalls in staff practice related to infection prevention and control, we also found potential infection risk from topical cream administration listed below, improvements were needed.

A person who sometimes applied their prescribed topical creams on their own told us they could sometimes forget to apply it due to their memory. However, their care plans did not give staff any guidance on how to minimise the risk of them not getting this medicine. Their and other people's records did not have evidence that people always received their prescribed topical creams. However, people's independence was promoted with managing medicines; a person told us they were supported in managing their medicines as independently as possible; they told us they took their tablets independently, but staff carried out audits and helped with reordering. A relative said, "[Relative] self-medicates" and "[Relative] keeps the medication in a locked safe in the wardrobe and keeps the keys in [Relative's] pocket, but they (staff) do check the medication to make sure [Relative] has taken it and [Relative] lets them know when to re-order, and it's working well."

Due to our observations of staff practice, we were not assured that staff were always left uninterrupted while giving people their medicines, increasing the risk of errors being made. We were not assured staff gave people their liquid or dispersible medicines in line with their assessed needs when they needed their fluids thickened due to swallowing difficulties. We were not assured that staff always followed good hand hygiene when supporting people in receiving their medicines. In response to our feedback about medicines, the provider told us they had taken action, which included additional staff training and reviewed auditing processes. We will check for improvements during our next assessment.

The provider did not always manage medicines safely. We found gaps in staff, evidencing they had adhered to the provider’s cleaning schedules in areas where medicines were prepared. We found expired medicines were in use, and 1 person had been given an expired medicine. We observed several prescribed topical medicines in people’s rooms to be either expired, unlabelled with opening dates or contained pharmacy labels that were no longer legible, increasing the risk of people receiving medicines no longer safe for use. Staff had not always followed good practice with the documentation of controlled medicines.