Eden Holme Care

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 safe and protected from avoidable harm. The provider had made improvements and were no longer in breach of regulation 12(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 or regulation 19(3)(a) of the Health and Social Care Act (Regulated Activities) Regulations 2014 which requires providers to make available to CQC the information set out in Schedule 3. Systems and processes were implemented by the provider to ensure areas of risk in people’s lives were managed, learning took place to improve outcomes for people.

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.

People understood how to raise safety concern, as well as ideas for improvement, to the provider and were confident these were addressed. People were informed by the provider of the outcomes and improvements.

The registered manager and provider regularly analysed accidents and incidents to identify any learning, themes or patterns. Staff understood how to identify and report safeguarding concerns both inside and outside of the organisation and told us how they had received training in this area.

Systems and processes to ensure learning had taken place following accidents, incidents and complaints were in place and shared with the wider staff team. This meant staff were able to learn lessons and reduce the risk of similar incidents occurring.

People were involved in their transition into the service, their individual needs and preferences were assessed to ensure these could be met.

Staff worked with external professionals such as GPs and speech and language therapists to support people with their healthcare. The management team had built positive working relationships and systems with local healthcare practitioners to ensure people received support in a timely manner when required.

Feedback from partners acknowledged the improvements in outcomes for people as a result of the care team working with other professionals and specialists.

People’s care plans included important information which aided their transition into the service. For example, we found detailed information on people’s life history, likes and dislikes. We also found people’s care plans continued to be regularly updated following their admission, this ensured staff had accurate information on people’s current needs.

People felt safe using the service. People raised very few concerns but were confident these were addressed by the staff at the service. People told us staff knew them and were available when they needed assistance. People were supported in line with the guidance in their care plans.

Staff understood how to report any safeguarding concerns they had both inside the organisation and externally if required. Staff had received training in this area with regular updates and refresher opportunities.

People were supported in line with their care and support plans. Staff understood their responsibilities to keep people safe and ensured this was part of their daily practice.

Accidents and incidents were reported by staff to the management team who investigated and analysed the information to reduce the risk of reoccurrence. We found the management team had taken appropriate action when people had experienced falls, we found post monitoring records in place and medical advice had been sought when required. We also found equipment in place which to support people’s safety, and this was regularly checked by staff for safety.

The service had captured important information about people, including their background and current needs, a relative told us they had attended a review of their family members care and staff updated them regularly on any changes.

Staff had access to people’s care plans and risk assessments, so they were aware how to safely support people to manage any risks. Staff attended regular staff meetings where they were informed of any changes and updates to people’s care. Staff spoke positively about the provider’s electronic care system. One staff member told us, “It’s a good system, all documents are on this."

We saw people were supported to manage the risk areas of their lives. Staff demonstrated their understanding of people's needs and how to support them to positively manage risk.

Effective systems and processes were in place to ensure to ensure risks were identified, monitored and mitigated. The provider had systems in place to ensure staff had access to up-to-date information about people, the provider’s electronic monitoring system also ensured the management team could frequently check that when people’s known risks required monitoring.

People and their relative told us they found the service to be clean and safe.

The management team had systems in place to regularly check the environment for safety, this included a daily walk around and audits. Staff knew how to report any concerns and how they had received training in how to safely evacuate the building in an emergency

We found the environment to be safe.

We found environmental safety was well managed. Regular checks had taken place, thins included checks of fire alarms and water temperatures and the staff regularly carried out practice evacuations which aided them to understand the actions they would take in a fire.

People told us staff were available when they needed assistance, and we observed people to have access to call bells. Relatives told us about the assistive technology the provider had put in place when their family member was unable to use a call bell, this technology alerted staff as an early warning system to reduce the person’s risk of falls.

The service had adequate staffing levels and of the contingency measures in place for if staff had an unplanned absence to ensure the service remained safely staffed. Staff spoke positively about the training they had received and told us they regularly refreshed their knowledge to ensure the care they provided remained up to date and in line with best practice. One staff member told us, “The training is very good, [Manager] checks you know what to do after any training.”

Sufficient staff were seen to be available to meet people's needs safely.

During this assessment, we found the provider had made improvements to their recruitment processes and they were no longer in breach of regulation. We found staff were recruited safely; safer recruitment processes had been followed to ensure people were suitable for their roles. The management team had a dependency tool in place which ensured the needs of people were regularly reviewed to ensure suitable staffing levels were in place.

People were supported in a clean and safe environment. One person told us staff cleaned their room every day.

Staff had received training in infection, prevention and control. The management team regularly audited the infection prevention measures in place and how they had sought advice on best practice.

We found the environment to be clean and safe.

The provider implemented systems and procedures to support effective infection prevention and control. This included a regular walk around of the environment to check standards are met.

People were positively supported during times of fluctuating capacity. Systems implemented by the provider gave people the opportunity to consent to medicines prior to administration.

Leaders were knowledgeable about safe medicines management. Regular audits were conducted, and staff competence checks carried out. Staff told us of the steps they took to reduce the risk of any medicine errors, this included carrying out regular stock checks.

Medicines were managed safely; regular checks of the stock levels were carried out by staff. We found 1 PRN ‘as required’ medicine protocol lacked information on when the medicine should be offered or administered. The protocol did not provide clear detail on the actions staff should take before using the ‘PRN’ as a last resort. We raised this with the management team who told us they were in the process of updating the protocols to include this information.