Eden Mansions Nursing Home

The provider had a good learning culture and people could raise concerns. Overall, there were systems in place to assess and manage risks. However, the provider needed to ensure staff always followed procedures and comprehensive risk assessments were undertaken. The environment and equipment were maintained and kept clean. There were some actions in progress to further mitigate identified environmental risks. Whilst systems were in place to ensure people were protected from abuse, with any concerns reported, staff needed to ensure local procedures were always robustly followed. Further training was in progress in relation to this. The provider ensured people received their medicines as prescribed and these were well managed.

The provider ensured there were enough suitably trained staff. Staff felt they were fairly treated and supported through supervisions and other means. However, there were a few gaps in records to demonstrate all staff received supervision in line with the provider’s policy.

Whist staff undertook pre-admission assessments, these were often not in person, which could potentially impact the accuracy and completeness of information. The registered manager agreed to review this approach. Staff sought consent from people and made decisions in line with the Mental Capacity Act 2005 (MCA) where required. People were treated as individuals, and staff supported their preferences and wishes.

Leaders ensured people were at the centre of their care. People’s care plans contained person specific details including information about their lives and histories. We found staff were responsive and acted promptly in response to changes in people's presentation. They worked in partnership with other health and social care professionals. Care plans included information about how to support people’s health conditions. However, some care plans contained contradictory information, which staff addressed immediately.

Staff completed monthly reviews, although some relatives said they had not been involved in these. A team of wellbeing coordinators produced an activity programme including coffee mornings, karaoke sessions and outings.The management team were knowledgeable and understood their roles and responsibilities. We found them to be open and responsive. Quality assurance systems were in place. Leaders carried out various checks and audits and had recently completed an improvement plan. However, these audits did not identify or address all the issues we identified, including gaps in risk management and other records.

The provider continued to invest in the service and there was a strong focus on continuous improvement. They had a refurbishment plan in progress, along with other developments.