St Edwards Close

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’s relatives told us they thought their family members were safe living at St. Edwards Close. Comments included, “I like the staff I’m very appreciative of the hard and caring support they provide for my family member”, “Staff are really caring and they make sure [family member] is safe and at the centre of the care provided,” “Residents are safe and well looked after,” “I don’t visit that often but when I do I’d say there are enough staff on duty to keep people safe” and “Staff know people well and there is a good bond of trust between them”. Throughout our inspection we noted people looked happy, content and well cared for. We saw staff were supporting people appropriately and there were always staff members in the communal areas to support people. Relatives confirmed people were all treated with respect and supported in their lifestyle choices.

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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

Relatives of people told us they thought risks to people’s safety were well managed with good levels of staffing for each person. One person said, “I get the help I need from staff, they make sure I am safe.” A relative told us, “They closely monitor my [family member]. The staff know people well, most of the residents have been there a long time and so have many of the staff, so a good bond of trust has developed between them.” Another relative said, “Staff keep an eye on people and this helps to keep them safe.”

The registered manager and staff told us risks to people were assessed and the risks managed through people’s care plans. This meant they were appropriately protected and supported. We saw care plans and risk assessments were reviewed with the person concerned, their relatives, staff and local authority care managers. The registered manager told us if people’s needs increased, there were provisions in place for additional staff support to be provided as required.

The service had comprehensive risk assessments and risk management plans in place to ensure identified risks were minimised so that people and staff were helped to keep safe and protected. Regular service and maintenance checks of the home and equipment had been undertaken. There was an up to date fire risk assessment, a daily room and environment audit to help to ensure any risks were identified so they could be dealt with. We saw records that confirmed what we were told and we saw these had been maintained to date. We observed the home was clean, tidy and kept free of clutter. This meant that people could move safely around the home. We saw there were appropriate policies and procedures regarding the safeguarding of adults. Staff had signed each of the policies to demonstrate they had read and understood them and to show their agreement to follow them. When we spoke with staff they were clear on how to follow them and they said they had received training in the procedures for safeguarding people. This was confirmed by training records we saw. Staff described the types of abuse they might encounter and they knew what action to take if they had any concerns about the safety or welfare of people. They said they would report these to the registered manager or to the local authority safeguarding team. Processes and systems such as handovers, care record reviews, ‘residents’ meetings and keyworker support helped ensure risks continued to be managed safely and were effective in enhancing people’s lives. In addition, the service worked alongside families, significant others and health and social care professionals to help provide a holistic approach to risk management. Written accident and incident documentation records were completed. There was evidence of learning from incidents and changes were implemented. Monthly audits helped staff identify trends to avoid further recurrences.

People felt the environment was safe. People’s relatives told us they thought the environment was safe and well maintained.

Staff received regular training in fire prevention, they confirmed there were regular fire drills and fire alarm tests. Staff felt the home was safe for people and they told us they carried out risk assessments for people to help maintain their safety both in the environment and out in the community. We saw evidence in people’s care plans and risk assessments that supported this. The registered manager told us a refurbishment plan was in place to redecorate all the areas of the home [needing upgrading] in both units and this work would start as planned for September 2024. We looked at the plan and could see that all the areas noted were to be addressed in the plan. When the work is completed the concerns raised with us about this will be met. Despite the need for this refurbishment we found the home to be safe for people living there. We will monitor the progress of this work and will review it either at the next inspection or earlier if the need arises.

People were happy and there was a comfortable and friendly atmosphere in the home when we visited. Some people’s rooms were personalised to suit their wishes but others could be improved in this respect. The registered manager told us this was being addressed with people and choices for colour schemes had already been made by people for when their rooms are redecorated.

There were audits and checks taking place to ensure the environment was safe. A fire risk assessment was in place and fire drills were held so that staff were able to support people appropriately in the event of an emergency. Fire equipment was regularly maintained and serviced. Some fire extinguishers had recently been replaced following a maintenance check. Environmental audits took place to check for areas requiring improvement. People had personalised evacuation plans in place so that staff knew how they needed to be supported to safely evacuate the building.

People and their relatives told us there were enough staff who were knowledgeable and well trained and who provided safe and effective care for people. We observed there were good numbers of staff on duty who knew people well. Relatives told us when they visited their family members there were sufficient numbers of staff on duty to meet people’s needs. Comments received from relatives were positive and reflected a caring and responsible attitude that staff had in caring for their family members. People and relatives told us they felt staff were equipped with the necessary skills to support people safely and effectively. Comments included, “They are competent and know what is needed to help people” and “They [staff] know what to do and seem to be well trained.”

Staff received support through supervision. This included one to one meetings and team meetings. The registered manager acknowledged the frequency of these formal meetings did not always meet the provider’s own policy to do with staff supervision. The managers agreed to ensure regular six to eight weekly individual supervision meetings for every staff member. They also told us they would introduce a new supervision format that set out the agenda for supervision meetings and included the direct work staff undertook with people. These measures when fully implemented should ensure staff have the skills, knowledge and experience to deliver effective care and support. We were happy from staff comments we received that they felt appropriately supported by managers with their work. We will monitor the progress of this work and will review it either at the next inspection or earlier if the need arises. Staff told us they received training in core areas such as with learning disability, dealing with distressed behaviour, safeguarding, first aid, infection control, the Mental Capacity Act, food hygiene, equality and diversity, epilepsy, autism and the safe administration of medicines.

We looked at the staff rota and we saw that the staff ratio to people provided good cover to meet the support needs of people. The registered manager told us if people’s needs increased, there were provisions in place for additional staff support to be provided as required. We inspected five staff files which showed there were robust recruitment processes in place. Each file had a checklist to document all the stages of the recruitment process and to ensure the necessary steps had been carried out before staff were employed. These included criminal record checks, proof of identity and the right to work in the UK, declarations of fitness to work, suitable references and evidence of relevant qualifications and experience. This showed the provider had taken appropriate steps to protect people from the risks of being cared for by unfit or unsuitable staff.

A training matrix was in place that evidenced staff received all the training referred to above. Accident and incident reporting processes were in place, understood by staff and maintained to date. There was evidence of robust recruitment procedures. All potential staff were required to complete an application form and attend an interview, so their knowledge, skills and values could be assessed. The provider undertook checks on new staff before they started work. This included checking their identity, their eligibility to work in the UK, obtaining at least two references from previous employers and Disclosure and Barring Service (DBS) checks. The DBS helps employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable people. There were systems in place to review staffing levels against people’s dependency, these were reviewed regularly and inline with people’s changing needs.

People’s relatives told us they thought the home was kept clean with good cleaning schedules in place. Comments from relatives included: “The buildings need more regular maintenance in terms of the decor but infection control seems to be good,” and “People are kept safe. Staff use PPE, such as gloves and hand sanitizer and follow infection control processes”, “The home always seems clean but could do with a refresh.”

Staff told us they received good training in infection control and food hygiene that was regularly refreshed and which helped them maintain good practices in these areas of infection control. Staff were well aware of their responsibilities to ensure good practice and adherence to the policies and procedures in place.

We undertook a tour of the premises and found them to be well clean and free from infection. Inspection of fridges and freezers demonstrated food was labelled with opening dates as required.

Staff received training in infection control and food hygiene that was refreshed regularly. Appropriate cleaning schedules were in place and carried out to help minimise the risk of infections.

People told us they received their medicines as prescribed by their GP. This was confirmed by people’s relatives.

Staff told us they were responsible for administrating people’s medicines but only after they had received appropriate training and had their competencies assessed. Staff were aware of the actions they were required to take when there were specific considerations such as with people's PRN medication. Staff told us they regularly liaised with health professionals for advice. A health and social care professional we told us staff in the home liaised appropriately with them and this they said contributed to good coordinated joint work. This has helped to keep people healthy and safe.

Appropriate policies and procedures were in place for staff to follow to ensure the safe administration of medicines to people. Staff received appropriate training. Regular medicines audits took place to identify any areas for improvement. We reviewed the most recent of these audits. Competency checks were completed for staff responsible for administering medicines. The registered manager told us only staff who had received the necessary training were allowed to administer medicines to people. This was to help to ensure that people’s medicines were managed so that they received them safely. We found that there were appropriate arrangements in place in relation to obtaining, storing, administering and the recording of medicines which helped to ensure they were given to people safely. All the medicines were safely stored away in a locked medicines cabinet. We looked at a random sample of medicine administration record (MAR) sheets. We saw that staff administered medicines to people and maintained the records appropriately.