London Care (Ensham House)

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 means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

This key question has been rated Good. This meant people were safe and protected from avoidable harm. However, we found the provider did not always do all that is reasonably practicable to mitigate risks to people.

We found the provider was in breach of the legal regulation relating to safe care and treatment.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice.

Systems were in place to support staff to report and record safety concerns and events when these arose. However, these were not always investigated in a timely manner. For example, staff recorded any incidents and accidents which were then uploaded onto a reporting system for manager sign off. We reviewed the events uploaded since September 2024 and saw a number of incidents had gone beyond the expected 28 days resolution timescales. This meant there was a risk that learning was not always acted upon in a timely manner.

Learning following safety concerns was not always followed up to improve practice, reduce risk and keep people safe. For example, one person had 4 unwitnessed falls since November 2024. However, their falls risk assessment had been reviewed in July 2024 and had not been updated since these falls.

Similarly, there had been concerns raised for another person which indicated they were at risk, however this was not reflected in their risk assessments or care plans.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care.

People who were referred to the service were given an opportunity to tour the premises and their potential flats before deciding. Pre-admission records were shared with the provider so they could make an informed decisions about people’s suitability for a placement.

The provider worked with people and external health and social care partners to understand what being safe meant to them and the best way to achieve that. The provider shared concerns quickly and appropriately.

People told us they felt safe living at this extra care housing scheme. Comments included, “Yes, I feel safe” and “They look after me properly, I feel safe with the carers.”

Managers and staff understood how to safeguard people. They knew how to recognise and report abuse and were able to articulate how they would spot signs if people were at risk of abuse or harm. A member of staff told us, “Safeguarding is making sure people are safe from harm. We have to report any concerns to the managers.” Training records showed staff had received safeguarding training.

Managers worked with the relevant external agencies, when a concern was raised, and took appropriate action to safeguard people from further risk, when this was required.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Although people’s care and risk management plans contained information and guidance for staff on how assessed risks should be managed to keep people safe, these were not always updated in line with changing needs. We raised this with the provider who acknowledged the instances where risk assessments needed to be reviewed to ensure they were reflective of people’s current needs. This had been included in their ongoing improvement plan for the service. We were reassured with this response.

Despite this, we observed restrictors were appropriately attached to people’s windows to prevent the risk of falls from height. People had individual emergency evacuation plans to support them in the event of a fire and fire procedures were affixed to the back of each person’s front door. Appropriate health and safety checks were carried out and recorded.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Effective arrangements were in place to monitor the safety and maintenance of the premises, which a Housing Association as the property's landlord was responsible for. This ensured the building and equipment was maintained and serviced at regular intervals.

There was guidance available for people to report issues with their tenancy or their flats to the Housing Association,

Although the provider made sure there were enough qualified, skilled and experienced staff, they did not always work together well to provide safe care that met people’s individual needs.

People using the service told us that although their care visits took place and the care workers were kind and friendly, they were not always informed when care workers were running late and the timings were not always consistent. Comments included, “The service is alright but they don’t always tell us if they are running late” and “Sometimes they come late, they don’t always tell us. It’s not too bad but you would like to know.”

We were also told that staff were not always responsive when the emergency call bells were activated outside of their core visit times. They told us, “If I press my call bell, sometimes they answer sometimes they don’t answer it, it then goes to the call centre.”

There had been recent provider concern for the provider’s lack of responsiveness to the emergency buzzer which was upheld after an investigation. The provider had picked up on this area of concern and had recently sent out a memo to staff reminding them of their responsibilities to respond to the emergency buzzer in a timely manner.

The provider operated safe recruitment practices and only suitable staff were employed to work at the scheme.

Staff told us they generally had enough time to undertake their duties and provide people with the care and support they needed when they were fully staffed. However, they did say when staffing levels were below their expected levels, this did have a negative impact on their visit times.

Staff received training and were supported through supervision which helped to ensure they met people’s individual needs. Staff received a mixture of e-learning and in-person practical and theoretical training, which was routinely refreshed as frequently as staff required it including, in-person practical competency based assessments.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. People were supported to live in a clean, hygienic environment.

People were protected from the risk and spread of infection. Staff followed good hygiene practices to keep people safe. For example, staff wore personal protective equipment including single-use gloves when supporting people with their personal care. We saw hand gel along corridors for use by people, staff and visitors. We observed the environment to be bright and clean, wheelchair accessible throughout and with no malodours.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

People told us they received their prescribed medicines. However, records in relation to medicines support did not always follow good practice. In one person’s medicines risk assessment, there were no details of their prescribed medicines. Another medicines risk assessment had been completed in March 2023 but the information in this did not correlate to the information in the person’s care plan.

The records for 'when required' medications were incomplete and care workers did not record the reason for administration. Medicines stocks were not counted. This meant there was a risk that these medicines were unaccounted for.

We raised this with the provider at the time of the assessment who confirmed this had already been identified and included in their ongoing improvement plan for the service.