Archived: Walsingham Support - 21 Budge Lane

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

Family members told us they were not regularly asked for their feedback about care delivery. The provider was unable to demonstrate that incidents and complaints were properly investigated, reported and lessons were learned although family members were notified if people had an incident/accident. Most family members felt that people were safe living in the home, although some family members did raise safety concerns.

The provider was not ensuring people were safe from the risk of abuse and that their rights were protected. The provider could not demonstrate that people using the service whose liberty was being restricted was done so legally and in their best interest.

Leaders were aware of the need to ensure continuity of care. However, the management team in place were new to their roles and required time to get to know the home and people living there before making the necessary changes. The provider was not consistently working with partners to establish and maintain safe systems of care.

The provider did not consistently ensure risks to people’s health and safety were being managed although staff were following good practice principles when using moving and handling equipment.

The home required decoration and was drab in presentation. The environment was not dementia friendly.

Staffing levels were not meeting the needs of people using the service. Managers could not demonstrate people were supported by staff who had received relevant and good quality induction at the service. Some staff had not received up to date training in areas such as moving and handling. Regular supervision sessions were not taking place and the provider could

not fully demonstrate safe recruitment procedures.

The provider was not consistently assessing and managing the risk of infection. Systems were not robust enough to ensure safe management of people's medicines.

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.

Family members told us they were not regularly asked for their feedback about care delivery. Satisfaction surveys were not being requested to be completed by most of the relatives and they had rarely been invited to the family members’ meetings. Comments included, “Not had any [questionnaires] if we are satisfied. No feedback at all, no correspondence or emails, nothing”, “I had a meeting round the table, residents and relatives, one meeting in four years. No questionnaires for [service name], I don’t recollect one” and “No I haven’t [been asked to complete a feedback questionnaire about the service delivery]. They do these Zoom chats periodically for parents and carers. One coming up in a couple of weeks, on 7th November.” The management team told us that recently they held individual meetings with the family members to inform them about the changes at the service.

The Duty of Candour is a regulation that all providers must adhere to. Under the Duty of Candour providers must be open and transparent if things go wrong with care and treatment. During the inspection, the management and staff teams applied duty of candour as required. They supported the inspection team and honestly shared information with us in relation to the challenges the service was facing and where they required to improve.

The provider was unable to demonstrate that incidents and complaints were properly investigated, reported and lessons were learned. There was an accident and incident and complaints policy and procedure in place that stipulated the process as well as responsibilities. Although the provider kept a log of accidents and incidents and complaints, which showed what had happened and what actions had been taken as a result, they were unable to produce copies of the records relating to individual incidents. As a result, we were unable to see what specific investigations had been conducted and what specific actions and learning had been taken as a result of incidents.

Family members were notified if people had an incident/accident. They said, “Incidents like the one before, [the staff team] ring me”, “Yes, [my relative] did complain once, she [had an accident] and I was told” and “I hope they would, they used to ring me.”

Leaders were aware of the need to ensure continuity of care. However, the management team in place were new to their roles and required time to get to know the home and people living there before making the necessary changes. We saw actions being taken soon after our visit to address the issues we identified. This included carrying out a full medicines audit to ensure people’s medicines were managed safely.

The provider was not consistently working with people and their partners to maintain safe systems of care. We received feedback from the local authority to indicate that information about people’s needs was not being consistently shared with them as required.

The provider was not consistently working with partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. People’s care records included evidence of joint working with multi- disciplinary professionals for people’s care needs. The provider had systems in place for sharing information with the local authority, but these systems were not being followed after the departure of the previous manager and during the transition to new management.

Most family members felt that people were safe living in the home. However, some safety concerns were raised by family members involving incidents for example, in relation to people’s medicines management and use of equipment. Their concerns were mainly regarding the communication with the home and lack of updates from the managers about the actions being taken to ensure their relatives’ safety. Some family members also told us that due to on-going management changes, they were not sure who they should be contacting at the service if they had any concerns about people’s safety.

On the day of our visit, we also saw that staff had not always been asked to sign in and out making sure the home retained an accurate record of everyone on-site for safety measures.

Staff provided us with examples of how they supported people to make everyday choices. Their comments included, “We know what [people] like, sometimes they are telling us. [Name of a person] was saying he wanted cornflakes today. We show clothes to [people] and they say- this one!” and “You let [people] know what choices there are for choosing, like the food. You could ask [a person] if they understand what you are saying and if not, we could use pictures if the person is not verbal.”

People felt comfortable around staff and were able to ask staff for support when needed. Staff referred to people using their first name.

The provider was not following its own systems to ensure people were safe from the risk of abuse and that their rights were protected. The provider had a clear safeguarding policy and procedure in place that stipulated what was supposed to happen in the event of an allegation of abuse. Whilst the acting manager showed us a log of all safeguarding incidents, they were unable to provide us with evidence of investigations undertaken in relation to these concerns.

The provider could not demonstrate that people using the service whose liberty was being restricted was done so legally and in their best interest. We found that some people using the service required a Deprivation of Liberty Safeguard (“DoLS”) authorisation in place to keep them safe. DoLS ensure that people are only deprived of their liberty when it's necessary and in their best interests. However, some people with a DoLS in place did not have authorisations in place that were in date.

Staff supported people to take calculated risks making sure people were able to do the things they wanted. A family member commented, “Yes staff that work there do the job well. They take [my relative] shopping and nothing went wrong. [Staff] introduced [my relative] to get on buses and off. Normal life supervised.”

People were provided with special equipment which enabled them to ask staff for support quickly when they needed it. Staff were aware of the actions they had to take to ensure a person’s safety if they had an epilepsy seizure.

Staff had access to information about the risks to people’s safety. We saw people’s individual care plans being displayed in the office and easily accessed by the staff team when needed.

The provider did not consistently ensure risks to people’s health and safety were being managed. All people using the service had clear care plans as well as risk assessments which identified the risks and included risk management plans for mitigating those risks. However, we identified two examples of risks to people’s care that were not managed through a specific risk assessment. This related to one person’s risk of pressure sores and the risks associated with another person’s moving and handling. The provider created a moving and handling risk assessment for one person, but did not create a skin integrity risk assessment for the other person. We also identified an example of another person with a specific health condition, for which there were no written instructions for care staff.

This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There was enough equipment to support people safely. Family members’ comments included, “Yes, [the home] had been very good since [my relative] moved there. They provided an armchair and a commode shower chair, better than what [my relative] took with her” and “Hoisting is good I think, [my relative] is fine. They made efforts to accommodate [my relative] with his chair, they put things on the walls so not to scar the walls.”

Staff followed good practice principles when using moving and handling equipment to minimise risk. They said, “We use hoists. We have to be careful and keep an eye on the person and if the hoist is ok before you start using it. 2 staff always do the hoisting” and “For manual handling, first we need to make sure all the equipment is safe to be used, if it's charged and well-functioning.”

At the time of our assessment the home required decoration and was drab in its presentation. The environment was not dementia friendly as there were no clear navigation points to support people with dementia to orientate themselves. The provider agreed decoration and was needed and did have plans in place to do so.

At the time of our assessment, the provider had plans in place to redecorate the home. The provider had a spreadsheet showing the works to be completed within the building along with the level of progress they had made with these, however, we saw there were no recorded dates for redecoration works. The provider conducted maintenance checks throughout the building which included fridge/ freezer daily temperature checks, radiator and water checks among others. We also saw there was a clear environmental risk assessment in place which demonstrated the building was safe for people to access.

Staffing levels were not meeting the needs of people using the service. Although most family members told us there were enough staff scheduled to work during the day to care for their relatives within the home, we found there were not enough staff to support people to go out when they wished to. This was discussed with the management team who told us the staffing levels would be reviewed.

Managers could not demonstrate people were supported by staff who had received relevant and good quality induction at the service. We found that staff induction was not always appropriately completed, and actions were not taken to ensure staff had read people’s care plans before they started supporting them. Managers could not demonstrate they took the required action to ensure agency staff had the necessary skills and knowledge to support people living at the service, including appropriate training to ensure safe care delivery.

Tasks were effectively shared between the staff team to ensure they were completed. Suitable staff were allocated to support people with personal care tasks, cooking and room cleaning duties. A communication book was used to effectively share information between the staff team.

The provider did not ensure there were enough skilled and experienced staff supporting people. The provider was unable to provide any evidence to demonstrate how staffing numbers had been calculated and that these numbers were appropriate to support people. The provider did not ensure all staff received an induction and ongoing support to support them in meeting people’s needs. The provider did not have evidence to demonstrate staff inductions had taken place for all staff at the service. Training records showed some staff had not received up to date training in areas such as moving and handling. The provider kept a record of training that had been completed and when, but this did not include evidence to demonstrate training that had been completed, for example in the form of certificates. This meant there was a risk that some staff were working with people, without having the skills to do so. Regular supervision sessions were not taking place with staff. Some staff had not received a supervision session for over six months. The provider was also unable to show notes of supervision sessions with staff, so did not have an accurate record of matters discussed during sessions that were taking place. This meant some staff were at risk of not being supported in their roles when needed.

This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider could not fully demonstrate safe recruitment procedures. Staff files showed some pre- employment checks were being conducted, for example all staff had a valid Disclosure and Barring Service (DBS) check in place. DBS helps employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable people. However, the provider was unable to show valid right to work documentation for all staff. This meant people were at risk of being supported by people who did not have the right to work in the UK.

The service had good arrangements in place for keeping the premises clean and hygienic. Family members told us that the home was, “Well maintained”, “It’s not bad, lick of paint here and there and in dining room. Looks clean”, and that “[Staff] do seem to do a good job [maintaining the home clean].”

Staff confirmed they were supported to maintain good infection control within the service. Staff told us there was adequate personal protective equipment (PPE) and wore this as and when needed, including during personal care tasks and when undertaking meal preparation and cleaning chores to keep people safe.

The environment appeared to be clean and tidy, and there were no odours. Hand sanitisers and soap were available to use for staff and visitors to prevent catching and spreading infections. Cleaning materials were kept in a locked cabinet and only authorised staff had access to it.

The provider was not consistently assessing and managing the risk of infection. Although the provider had a clear infection control policy and procedure in place, there was no evidence of infection control auditing taking place. The provider did not produce any evidence of cleaning checklists or monitoring of the cleanliness of the building or infection control through effective auditing. We were therefore not assured that procedures to maintain the cleanliness of the building and management of infection control were being followed.

Family members told us that people received their medicines when they needed it. Comments included, “As far as I know, [my relative is given medication] in the morning, teatime and in the evening. [My relative] has a communication book, I look at that and it says in the morning given her medication” and “If [name of the relative] is in pain, he asks for paracetamol and he gets analgesics when needed. [Staff] told me they get regular visits from District Nurse. I’m sure they are checking his medication needs.”

Staff knew the actions they had to take in the event of medicines mismanagement. A staff member told us they would, “Report, seek medical advice and monitor the service user” if a medicines error had occurred and in relation to the medicines being refused, they said, “We don’t have it here, residents take their medicines. If they don't, we try again [encouraging a person to take their medicines] and we ask the manager to help.”

Systems were not robust enough to ensure safe management of people's medicines. People’s medicine records were completed consistently and included dose, time and name of the medicines being given to people. However, people’s medicines were not always stored securely. People’s medicines were kept in a cupboard and in a smaller individual cabinet within, one of which we saw not being locked for a period of time during our visit. We also observed a cup with the medicines being left briefly unattended by a staff and in reach to someone who had not been prescribed these medicines. This meant that people were put at risk because staff had not always followed systems and processes in place to store and administer medicines safely.

This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.