The West Gate

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

We found people were not always kept safe and there were 2 breaches of regulation. Accidents and incidents had not always been analysed for patterns and trends. Action had not been taken quickly to reduce the risk of them happening again. People had been placed at continued risk as lessons had not been learnt. Some incidents had not been recognised as potential safeguarding concerns and had not been reported to the local authority as required. Potential risks to people’s health and welfare had not been consistently assessed. Some care plans did not have consistent information and guidance for staff to keep people safe. Medicines were managed safely, and people received their medicines as prescribed. Staff followed infection control guidance and used the appropriate equipment when supporting people. There were enough staff to meet people’s needs.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

One person described to us how they and staff had learnt lessons together when the person had placed themselves at risk of harm. They told us staff had removed risky items from their bedroom and these were gradually being returned as the person felt well enough to manage them. They also received more frequent staff checks to ensure their wellbeing. However, this had not been done as soon as the person put themselves at risk. A relative told us staff had been “proactive” in working with health care professionals to find out why their loved one was falling. Changes were made to the person’s medicine and the relative said the falls had reduced by “80%”. Other relatives gave us examples of how their loved one’s care had changed following accidents and they had not reoccurred. Relatives told us they were always informed of any accidents and they and their loved one received an apology.

Staff were able to tell us how they report any accident, incident or near miss and what actions they would take to ensure people were safe and well. Staff described how they did this and told us they felt involved in the action taken. We were told that the registered managers both value the input from staff working with people . A registered manager described to us the process the provider had in operation to audit accidents and incidents to look for patterns and trends. When these were identified action had been taken to prevent them from occurring again. For example one person had slipped on the edge of their bed because the pressure mattress they were using was not supportive. The type of pressure mattress had been changed and the person had not fallen again. They had also been referred to the physiotherapist for support. They had also noted the same three people had been involved in several incidents. Action had been taken to encourage the people to stay away from each other, such as sitting in other areas. They told us there had been some ‘near misses’ but staff had supported people to remain calm. We were told, lessons had been learnt when someone left the service without staff knowledge. A registered manager had investigated what had happened and arranged for an additional lock to be fitted to the front door. However, this action had not been completed when similar incidents had happened previously.

There was a process in place to monitor accidents and incidents for patterns and trends, this process had not always been effective and placed people at risk. Incidents had not always been recorded on a central log, and action had not been taken. This had allowed the incidents to happen again, there had been 3 incidents where people had left the service by the front door. On 2 occasions, staff had not realised people were missing until they had been contacted by the police. The management team had not acted until the third incident. Incidents had been recorded but the information had not been recognised as indicating a decline in a person's mental health and risk of significant harm. There was guidance in their care plan to support the person during these periods, but this had not been followed. The lack of action by management enabled the person to place themselves again at risk of significant harm. Action had not been taken until a third incident had taken place.

Relatives told us staff worked well with health care professionals to ensure people got the care they needed. They knew about a recent change in people’s GP practice, to one which specialised in supporting care homes and confirmed a health care professional was contacted when people’s health needs changed. A relative told us, “My relative has had a few hospital trips due to their health and the home sort this, such as transport etc”. Another relative told us staff had enabled their loved one to have a medicines review with their new GP practice when they moved into the service. This was something the relative had been requesting from the previous practice but had not been provided.

Staff told us that they work with people’s GP or social workers for example, when people first arrive at The West Gate, to ensure they know as much as possible about them. Staff told us, “We are starting to learn how to make referrals to Speech and Language Therapists. Our head of care is teaching us and we will pass down through to support staff. Our nurses go round with the GP when they visit as they are best placed to inform them of people’s conditions.” Another told us, “What I have started to do is look at what we have, there is a pen picture that we put out to family if people cannot tell us about themselves. There was a lady who we did not have much information for but we gave this to their next of kin. That worked really well. We also work closely with people’s friends and family so we can get to know people better.”

Feedback from other healthcare professionals had been positive. We were told, staff provided the information they needed to provide safe transfer between services.

There were effective processes in place to make sure information was sent with people when they attended health care appointments or stays in hospital.

People told us they were confident to raise any concerns they had with staff and registered managers. Relatives told us the registered managers were approachable. Their comments included, “The home is safe and staff and the manager is approachable. Staff are lovely, any concerns raised they will investigate” and “The manager is very approachable, always has time to listen."

Staff we spoke with were able to demonstrate they recognised the signs of potential abuse and what they would do to report and keep people safe. We were told, “I feel so comfortable with the management. The new registered managers are amazing. They are both registered nurses so they know what it is like to be on the floor. We can approach them and they help.” The registered manager present during the visit was able to tell us what they would do if staff raised concerns for people’s safety to them. They understood their responsibilities to raise incidents or concerns and to be open and honest about what had happened. However, they had not always followed this process.

We observed people had positive interactions with staff. People were confident in staff’s company and were relaxed when chatting to them. Staff responded quickly when people were distressed. For example, one person was cold as a window was open, staff closed it when they communicated they felt cold.

There were processes in place to report safeguarding concerns to the local authority, however, this had not always been followed. There had been incidents which had not been identified as a safeguarding concern. The incidents included when people had left the service, the first 2 incidents had not been reported to the local authority. This had placed people at continued risk as the local authority had not had the opportunity to investigate what had happened. Some people had Deprivation of Liberty Safeguards (DoLs) authorised and included in these authorisations were conditions the service was expected to enact. There was no process in place to make sure any conditions were acted on as quickly as possible. There were some DoLs in place where conditions had not been acted on for 8 months, this placed people at risk of being restricted without authorisation.

People told us they had been involved in planning how risk would be mitigated. One person told us they were happy to use the rails on their bed as they made them feel safe, another person told us they had decided not to have the rails up. One person described to us how staff made them feel comfortable when they were hoisted. They told us staff talked them through the process and supported them to be involved. They told us they felt safe whilst being hoisted and the staff made them feel safe. People told us they felt safe when staff supported them. One person told us, “I feel safe when staff help me. I wouldn’t feel safe walking without them”. People told us food was prepared in the ways they preferred and was “easy” for them to eat. A relative told us staff were aware of their loved one’s variable mobility and were “close by if they’re wobbly". Another relative told us they were anxious when their loved one moved into the service, “but I soon realised they were on top of everything”. A relative told us their loved one had “enough kit” to keep them safe, including a falls alert mat. They told us staff came “quite quickly” when it was activated. Another relative told us staff had been concerned about their loved one’s safety and they had agreed together to change the person’s bedroom to mitigate the risk.

Staff told us where they would review assessments of the risks to people when living at the service. We were told, “We complete care plan reviews once a month with our resident of the day system. This is where we review at least one person a day for instance we review room number 1 on the first day of each month. Our heads of care complete people’s risk assessments. All risk assessments are really clear on the system. There are also pictures which is really helpful as I live with dyslexia." Nurses we spoke with told us, “Wounds people may have are reviewed every day. We keep records and these form part of our checks.” Each person who used a wheelchair had visual checks completed monthly by staff to ensure they were safe for the person to use. Feedback from the registered manager, showed they were not aware of all the incidents which taken place at the service and risk assessments had not always been updated.

We observed that pressure relieving equipment was set correctly to reduce the risk of people developing pressure ulcers. People were supported to take risks if they wished. For example, one person disliked changing their position to reduce the risk of developing pressure ulcers. We observed people being supported to sit safely. Staff encouraged one person to “wiggle back in the chair”, so the person would not slip off. The person received a drink of their choice in an adapted cup and drank without support. Other people were offered drinks in cups and glasses which met their needs. Food was prepared as recommended by healthcare professionals to mitigate the risk of people choking. Staff supported one person at risk of choking reminding them, “Take your time, swallow before you have some more”. Were they wished people were supported to continue to complete household tasks. One person did their own laundry including ironing. When people were at risk from falling out of bed, bed rails were used to support them. These were seen to be used correctly and covers were fitted to reduce the risk of people knocking themselves on the rails or becoming trapped in them.

Potential risks to people's health and welfare had been assessed. However, there was not always personalised guidance in place for staff to follow to mitigate risk. There was not always detailed guidance about how to support people when they expressed their distress non-verbally and how staff could recognise the triggers. The guidance for staff was generic and did not reflect people's needs, for example, a person was living with diabetes and the guidance for staff when they had high blood sugar was for them to walk around. However, the person was not mobile and was physically unable to walk. Some people were at risk of isolation, the guidance did not reflect their specific needs and give specific guidance for staff to reduce the risk of becoming isolated. The information contained in some care plans was not consistent, such as, how people were moved and what equipment to be used. Care plans had not always been updated when people's needs changed. When a person's supplements had been reduced and they started to lose weight again, this had not been reflected in the care plan, or evidenced they had been referred back to the dietician. When incidents had occurred, people's actions had not been identified as an expression of their feelings. One person had tried to get out of bed while they had bedrails in place and had trapped their legs. Additional foam wedges and mattress had been put in place to reduce the space between the mattress and the bedrails. The person had become trapped again by removing the foam wedges, this time including more of their body. The continued restlessness of the person, had not been considered as a risk of further entrapment, the decision to remove the bedrails had not been taken until after the second incident.

The weather was warm on the day of our inspection. There was enough ventilation and people told us they were comfortable. Relatives told us they felt the environment was safe. A relative told us, “The front door is locked, and no one can enter without it being opened”. Other relatives agreed saying, “Getting out of the building is harder than getting in”.

We completed a walk around the building whilst speaking with the registered manager. They told us that the building is older but has had some modern works completed and has been extended. We found the building to be clean, was odourless and was bright and airy. The registered manager told us they had keypads on doors to ensure people who can mobilise independently were safe. All cupboards that are to be kept locked were locked, including the boiler room, laundry and sluice and COSHH cupboard. The registered manager told us they complete reviews of the health and safety record book. This included, “Communal staff call system, communal area window restriction checks. We complete monthly hoist slings and straps checks. Hoists are serviced by Southern County care completed regularly.” We reviewed records of these which supported what we were told. Each service user's room was checked each month, looking for things such as window restrictors, call points, extractor fans, bed rails, mattress weights, ensuite lighting. Staff told us, when asked about the environment, “I love it. It's nice and fresh, we have a really nice contrast of light blue and dark blue. It's colourful and it smells lovely. I do not think I would change anything at the moment.” And, “It is such a lovely place to work. The garden is lovely and is accessible by people who live here.”

The environment, including the garden was safe and accessible. We observed people moving around the building independently and going out into the garden when they wished. Chairs were easy for people to get in and out of, and had arm rests people could use to support them to stand up.

There were processes in place to make sure the environment and equipment people used is safe. The provider has a plan in place to update and make improvements within the building.

People told us staff were helpful, kind and caring. Their comments included, “[Staff member’s names] are excellent, extremely helpful” and “I cannot think of one member of staff who is not a lovely carer. The staff are very very caring”. Relatives told us there were enough staff to meet people’s needs. One relative told us, “When alarms have gone off, staff are off as ‘quick as a rocket’”. Another relative told us they had accidentally stepped on the alert mat in their loved one’s bedroom and “A member of staff was there within in about 30 seconds”. Relatives told us staff had time to spend with people doing what they wanted. Their comments included, “If [person’s name] wants to go in the garden there’s always someone there to take them, staff take the time to do their hair and put nail polish on them”, “There are always staff on hand to talk to my relative” and “I often see staff sitting with my relative, holding their hand. Staff are not sitting clockwatching while taking time with the residents”.

We found that there were enough staff on shift during the assessment visit. Staff told us, "Sometimes we can be over staffed, but generally the staffing ratio is so good. I used to work here as a carer many years ago and there was nowhere near enough staff. We have one staff in the lounge 24/7 which has made such a difference with reducing the risk of people falling, and to make sure people are safe when interacting with one another." The registered manager told us that staffing levels were based on people's individually assessed dependency scores. "There is a dependency tool on our system. The team leaders review people's dependency monthly and update the system to ensure we have enough staff to meet people's needs. We can adjust this, accordingly, say for example some people are not in the service or if they become unwell, we can increase or reduce staffing numbers as needed." The registered manager told us they don't have any vacancies at time of assessment but do know that some hours will need recruiting to soon due to staff circumstances. the service has dramatically reduced its use of agency staff. Another staff member told us, "There is enough staff it is never dangerously low. They have increased the numbers much better than before. Never have agency, hardly ever now." New staff were given a mentor, we were told, "when we mentor, we can identify improvements from the start, which means we can support this earlier and ensure that the correct way of doing things is maintained." Staff told us they felt the training was sufficient to enable them to do their jobs correctly. The felt that supervisions were regular and supported them to understand what they are doing well and what may need improving.

We observed there were enough nurses and care staff to meet people’s needs. Nurses had the skills to meet people’s physical and mental health needs, including medicines management. We observed staff had time to spend with people. People were not rushed, and staff supported people at their own pace. At lunchtime staff supporting people with their meal, spent their time solely with the person, and people and staff appeared relaxed. We observed staff supporting people to move around safely. For example, staff used safe techniques to support a person to sit themselves up in a chair, the person was encouraged to do as much for themselves as they wanted, and staff supported where needed.

There was a process in place for staff to receive regular supervision, however, this had not been followed. Some staff had not had a supervision during 2024, and other staff had only had one this year. Staff had not always had training to meet the needs of people, for example, staff had not received catheter care training. New staff employed by the service had been recruited safely. All appropriate checks including the right to work and reference checks had been completed. When new staff start supporting people they are given a mentor, an experienced member of staff, who is available for support and guidance.

People told us they felt the service was clean. They told us their bedrooms were cleaned regularly and the cleaning staff were “very good”. People confirmed staff wore the correct personal protective clothing including gloves and aprons when they supported them with personal care. Relatives told us they service was clean when they visited. Their comments included, “It always smells clean and fresh, obviously there is the odd accident but cleaned up quickly, there’s always someone going around with a mop and cleaning trolley”, “I always see the cleaner going around with the trolley” and “Sometimes I can go down the corridor and there can be a smell, but it’s usually when people are being cared for, but the home is clean and tidy”.

Staff told us there had been an "Improvement in the general cleanliness of the service. The service was odour free and looked very clean throughout." There were plenty of domestic staff available who told us, "We have everything we need to make sure it's a nice clean environment." Staff told us, "We have plenty of personal protective equipment. the managers also sourced different kinds of gloves as there are a few of us who were allergic to the main ones." Staff told us about the difficulty of supporting people during the COVID-19 pandemic. They said "We learnt so much during those times. Although it was so hard, we have managed to keep a few procedures that worked well. For example, we had someone who had an infectious condition for a while. We had all of our barrier stations from the pandemic, and these were easy to reintroduce and keep everyone safe."

All areas of the building and equipment were clean and odour free. PPE was available and we observed staff wearing gloves and aprons when handling food.

There were systems in place to check the cleanliness of the service and audits were completed regularly. There were enough domestic staff to maintain the cleanliness of the service.

People told us they received their medicines when they needed them, their relatives agreed. One person explained how they applied their own prescribed cream. Another person told us they trusted nurses to order their medicines at the correct time. Relative comments included, “All the nurses give medication to my relative and they get it when needed”, “The nurses administer the medication and there’s no issue with this, my loved one has pain relief as and when they need it, and the nurses are very good in this respect” and “If my relative refuses, staff always go back and encourage them to take it. There hasn’t been a day where staff haven’t not given it to them”.

Nurses explained to us how they offered people their medicines and if they refused, they were administered covertly. For example, if one person refused their medicines they were crushed and administered with their favourite breakfast. Nurses explained to us how they safely administered medicines to people with a PEG. This including flushing the tube with water between each medicine to stop it from blocking.

Effective systems were in operation to order, store, administer, record and dispose of medicines. Some people’s medicines were administered without their knowledge, known as covert administration. Where decisions had been made in people’s best interests to administer medicines, detailed guidance had been put in place in consultation with the GP and pharmacist. This included the order to administer medicines to ensure the most important medicines were administered first, in case the person did not take them all. Systems were in operation to check the balance of high risk medicines each day. Records showed this had been completed as required and any issues had been identified.