Westhope Lodge

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

Staff did not always assess risks to people's health and safety or mitigate them where identified. Risk assessments were sometimes incomplete and did not always include risks we identified during our assessment. Medicines were not always safely stored and some medicine protocols guidance for staff were incomplete.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were not always supported by staff who fully understood what constituted an incident, which meant there were inconsistencies in practice. For example, some incidents of anxiety were recorded and some were not. People and their relatives spoke positively about the staff and management team. They told us they could approach them with any ideas, worries or concerns. They had confidence action would be taken.

Systems were not always effective in highlighting shortfalls in incident recording. Staff were not clear with how to report and record incidents. For example, when as prescribed (PRN) medicines were given for the management of anxiety, staff did not record the issues leading up to the administration of the medicine as an incident. The registered manager was able to demonstrate they knew about these occurrences but had not reviewed them against other things happening in the person’s life to try and identify the thing that may trigger the anxiety and could be avoided. This failed to demonstrate effective incident reporting systems had monitored shortfalls in reporting concerns or provide assurance lessons were learnt. Staff told us they recorded most issues on handover or daily log sheets and told the registered manager.

Providers processes failed to identify shortfalls in staff practice and a number of concerns were raised during our assessment visit. These included poor or no recording of some incidents where medicine had been administered. Incidents not recorded on the providers system did not allow the provider to have full oversight of incidents. Following our assessment visit we sought assurances from the provider of the actions they were taking to ensure people’s immediate safety and well-being.

A relative told us their loved one’s move into Westhope Lodge had been detailed and included visits to on a number of occasions before they moved in. There were concerns from some people before moving, which the registered manager addressed. People already living at Westhope Lodge told us they had been asked how they felt about a new person moving in and had time to get to know them before they moved in.

Staff had received information to guide their support of the new person moving in. Risk assessments and support plans had been developed, however these did need improvement, for example fully explaining why the risk assessment was in place so staff could clearly understand the level of risk. The registered manager updated the documents during the assessment visit.

The feedback we received from health professions was positive, commenting on staff engagement and interest to understand what the health professional needed from them to support people well.

There were systems and processes in place to support safe care, however these relied on staff and managers knowing people well, there was a lack of detailed recording particularly in daily records and handover documents to support effective analysis of trends.

People told us they felt safe at the service. One person said, “I feel safe now, no problem now but there was years ago, [name of registered manager] sorted it out]”. Another person told us, “I feel safe here” and then explained how they would complain if they needed to. A family member told us, “Safety is brilliant here all the time she has been here it’s been safe”. Another family member told us, “I have no concerns about abuse, never seen bruises and she is always happy to go back after being with us.”

Staff demonstrated knowledge about how to assess and manage safeguarding risks. Staff told us they had confidence in all managers that concerns would be addressed if raised and felt the culture was good and things were discussed openly. Staff told us morale was good and everyone enjoyed working with each other. There was a good sense of teamwork.

We observed staff and people sharing friendly and relaxed conversation. Generally, staff asked people what they wanted and offered some choices, in particular around eating and the type of food available for lunch. However, one person was not asked and staff appeared not to consider them in the conversation.

Deprivation of Liberty Safeguards (DoLS) processes had not been effectively monitored. A number of people were subject to Deprivation of Liberty Safeguards (DoLs). The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty had the appropriate legal authority and were being met. People had recently been referred for consideration within the DoLs framework following an internal quality audit. However, at least 1 person’s capacity to make their own decisions was not in doubt. There had been a confusion in understanding about what circumstances a request to deprive someone of their liberty should be made. The registered manager took action to address this issue on the day of the assessment visit.

Risks were managed in a way to ensure people were able to be as independent as possible and could enjoy activities they liked doing. For example, people told us they wanted to make their own hot drinks, however the kitchen did not have a kettle but instead used catering hot water urn, with hot sides which would have been a high risk. No effort had been made to change the urn to a suitable accessible kettle to support people. Since our assessment visit the registered manager has arranged purchase of a non-spill kettle.

The registered manager told us they were working on developing risk assessments further, however at the time of our visit there were a number of missing or incomplete risk assessments in place. These covered bedrails which were fitted on a person’s but not in use, safe storage of medicines and detailed epilepsy in water risk assessments. The registered manager took steps to address these during and shortly following our visit. However, the practice of identifying and mitigating risks had not always been effective.

We observed staff supporting people in shared parts of the service. People were observed being supported with meals and drinks in line with guidance. However, we noted people were offered cold drinks in coloured plastic cups. We spoke with the registered manager who understood the cups looked childlike but felt glass would be a high risk and ordered unbreakable tumblers which looked like ordinary drinking glasses.

The registered manager was responsive to areas of shortfall identified during the assessment and made swift changes. However, there had not been any effective oversight into how risk assessments were developed and monitored. Risks to people were not always identified or managed appropriately in the least restrictive way to promote good outcomes for people. For example, some people had Positive behaviour support plans (PBS). These are plans designed to support a person to manage when they become upset. These plans should contain detailed information to guide staff how to support the person and provide the person with opportunities to develop skills to help themselves in the longer term. These plans were sparse in their content and had been produced by the registered manager following what they told us was 1 days training. There was a failure to ensure staff were provided with appropriate training and guidance to ensure risk assessments were monitored in a consistent and safe way.

The provider did not always effectively manage risks and provide maintenance in a timely way. For example, a person told us the lift had been broken for months and they couldn’t help with their laundry as the machines were upstairs. A relative said people could not use the garden safely because it had become overgrown. People knew regular safety checks needed to be carried out and told us about fire drills and wheelchair checks.

Leaders told us they were aware there was maintenance work to be carried out and recorded these works on an action plan following our visit. Staff had received fire awareness training and understood the actions they should take should a fire occur. Staff were clear about the regular safety checks to be carried out. Staff told us they participated in regular training around all aspects of environmental safety. Records confirmed staff training and regular safety checks on equipment.

Observations of the environment confirmed safety checks were being completed for example, fire safety, electrical and moving and handling equipment had been serviced in line with regulation.

Systems were in place to identify and manage foreseeable environment risks within the service. However, maintenance of the fabric of the building was not carried out within reasonable timescales. This meant people, visitors and staff were not effectively protected from the risk of harm. Equipment was monitored and maintained according to a schedule. In addition, gas, electricity, and electrical appliances were checked and serviced regularly. Fire safety risks had been assessed by a specialist and where necessary action taken to ensure the environment was safe.

People told us they liked their staff and felt supported by them. A relative commented, “Staff are generally good, they do try, we have been impressed.” One person had a staff member with them all the time during the day who could have supported them to engage in their activities and interests, however, the person sat holding the staff members hand for hours in front of a television. This person's care plan stated that 1-1 staff should help engage with activities.

Staff told us they felt supported by the registered manager and they had supervision and appraisal meetings. Staff told us there were mostly enough staff but agency staff were being used.The registered manager told us 2 staff were starting soon from another one of the providers services and recruitment was ongoing with the aim to remove the need for regular agency use.

We observed staff not always engaging with people in an appropriate way. The use of over familiar language and gestures which could be seen as treating the person as a child was observed a number of times. We raised this with the registered manager who told us they would look at addressing this with training for staff.

Staff were safely recruited and received an induction and training in a number of topic areas. All staff had completed the care certificate. The Care Certificate is an agreed set of standards that define the knowledge, skills and behaviours expected of specific job roles in the health and social care sectors. It is made up of the 15 minimum standards that should form part of a robust induction programme. Staff training includes practice competency assessments carried out by the registered manager in the topic areas of medicine administration and moving people safely.

People were supported to manage potential risks of infection. Meals were prepared by staff who had received food safety training. People told us they liked the food. The service was generally clean and tidy, however some people told us the staff didn’t always have time to clean everything.

Staff were clear about their role in managing the risk of infection. Staff told us they had training and gave examples of where personal protective equipment such as gloves were needed.

We observed staff working in line with infection control and food safety guidance. However we did draw the staff attention to areas of a person’s bathroom where cleaning had been missed and an unpleasant odour had developed.

Infection Prevention Control Audits had been carried out and actions recorded and in progress. The service followed the principles of good practice guidance such as Safer Food Better Business (Food Standards Agency)

People were observed to have mixed experience of receiving support with medicines. For example, one person had creams applied to their legs in a shared space with other people present. However, other people had discreet and considerate support with medicines. People did not always receive PRN (medicine to be administered as needed) medicines safely or in line with good practice guidance. A review of people’s medication administration records (MAR) showed one person was prescribed a PRN medicine prescribed for agitation. PRN protocols and support plans failed to provide guidance to staff on when it was appropriate to administer this medicine or any associated risks. This was not in accordance with National Institute for Clinical Excellence, (NICE) good practice guidance. There was a failure to guide staff to consider alternative and preventative strategies prior to administering this medicine. There was no information as to what the reassurance techniques could be used by staff to reduce anxiety and agitation in the person’s support plan or PRN protocol.

Staff we spoke with were generally knowledgeable and were clear on actions they would take in the event of any medicine queries. One told us, “I would seek advice from managers who might suggest I contact the persons GP or call 111". However, our assessment identified some shortfalls with medicines practices and leaders acknowledged there were some improvements needed.

There were some shortfalls in medicine processes. There was a lack of suitable arrangements in place for storing, recording and auditing of medicines systems. Staff were not always storing medicines safely. For example, one person was prescribed rescue medicines for use in the event of a health emergency which were not stored securely in line with good practice guidance. Staff did not always record when they had given a person a prescribed fluid thickener powder at the time of administration. Audits had not identified the shortfalls we found at assessment. The registered manager took immediate action to ensure the emergency medicines were secured and amended medicines processes to ensure staff recorded at each administration of a fluid thickener powder. There were a number of shortfalls with medicines processes where risks to people had not always been fully considered and this resulted in a potential risk of harm.