Elvaston Lodge Nursing Home

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

Safe – This key question has been rated good. This meant people were safe and protected from avoidable harm. Systems were in place to manage safeguarding incidents and staff were trained in safeguarding people from abuse. Risk assessments were in place to reduce people's risk of harm. Care plans provided staff with an overview of people's care needs. Sufficient numbers of suitable staff were deployed, who received regular supervision and training.

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 told us when they had raised concerns, they had been promptly dealt with.

The registered manager told us about the systems they had in place to ensuring learning took place when things went wrong and how this was shared with the wider staff team.

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 told us they felt safe living at Elvaston Lodge. One said, “The staff are lovely, I feel safe here.” Visitors also told us they had no concerns and felt their loved ones were safe at the home.

The registered manager took the appropriate action for safeguarding concerns, this was in line with best practice and involved notifying other agencies.

Safeguarding concerns were reported, recorded and investigated. The registered manager analysed accidents and incidents to enable them to identify any emerging themes or patterns to improve the care provided. Risks which affected people's daily lives were documented within risk assessments. These were regularly assessed, and action taken as required to ensure people were supported in a safe and consistent way.

People felt safe, and staff knew them well. People and their representatives were involved in their care planning and staff listened and supported them with their needs.

The registered manager confirmed people, and their relatives were involved in their reviews of care and that they were kept up to date with any changes.

Staff encouraged people to maintain their independence safely and attended to them promptly when they needed assistance.

Risks to people were assessed, and measures were in place to reduce risk. This ensured people received care and support in a consistent and safe way.

People told us they felt safe living at Elvaston Lodge. One person said, “I think it’s very safe here. It’s well maintained and the staff are lovely. I am a lot safer here than at home.”

The registered manager showed us the systems they had in place to ensure regular checks of the environment and equipment used were in place.

Overall, the environment was clean and well maintained. Where improvements were needed an action plan was already in place to address this and work was in progress.

Risks relating to the environment had been considered and mitigated within people's care plans. For example, equipment was in place to alert staff if a person attempted to walk independently as they were high risk of falls. Incidents and accidents were escalated promptly when required. For example, referrals were made to the appropriate professionals such as the falls team or community mental health team.

People told us staff were available when they needed them and responded to call bells and also spent time chatting with them. We saw that staff were available to people when they needed support.

A dependency tool was used by the provider to determine the staffing levels in place. The registered manager advised us that following guidance from health care stakeholders, they were reviewing other dependency tools to ensure they were using up to date guidance. This was to ensure staff numbers and skill mix remained appropriate for the people using the service.

The provider operated safe recruitment processes. This included undertaking appropriate checks with the Disclosure and Barring Service (DBS) and obtaining suitable references. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

People and their visitors told us the home was kept clean. One visitor told us that although the home appeared clean, they were concerned that no cleaners were on shift in the afternoons and told us they had noticed an odour at times. We did not identify any odour in the afternoon but had noted an odour in one area of the home in the morning which we fed back to the registered manager. We noted this odour had gone later in the day.

The registered manager showed us the actions they had taken and were taking following an external audit of their IPC measures. The management team also regularly carried out audits to identify and action any areas of concern.

We did not identify any significant issues with the cleanliness of the home. We did find some areas that required improvement which the provider was aware of and an action plan was in place for these.

An infection prevention and control policy and procedure were in place, and followed by staff and audited by the management team.

People were supported by trained staff to take their medicines as prescribed and in their preferred way.

Medicines were managed safely and administered by nurses, who had received training. Any errors identified through audits were acted upon. This ensured lessons were learnt and improvements made, to mitigate the risk of future incidents.

Medicines were administered safely, and staff followed the policies and procedures in place.