Westwood Lodge Care Home

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 this key question has changed to inadequate. This meant people were not safe and were at risk of avoidable harm. The provider was in breach of the legal regulation relating to safe care and treatment, infection prevention and control and premises and equipment.

Medicines were not well managed. Not all care plans contained relevant, up to date information, which placed people at risk of not receiving the care and support required to meet their needs. The environment was not always safe or clean, and people were not always protected from the risks associated with infection prevention and control.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The new management team had a proactive and positive culture of safety, based on openness and honesty. However, this had not always been the case previously and lessons were not always learnt to continually identify and embed good practice. One staff member said, “We have raised concerns before, but we were never taken any notice of by the last managers.” The provider had processes for staff to report incidents, near misses, and safety events. There was a system to record and investigate complaints. However, evidence of learning from incidents and complaints was not always clear.

The provider did not always manage or monitor people’s safety. The provider needed to show evidence of outcomes in how they supported people, including when people moved between different services. Assessments were completed before admission and staff gathered information about people's needs prior to them receiving support. However, this information did not always transfer into people’s care records to provide staff with detailed, accurate and up to date information.

The provider did not always understand what being safe meant to people and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from avoidable harm and neglect. Some people continued to smoke in communal spaces and bedrooms risking the safety of others in the service. Before this report was finalised, we were made aware of a fire in a person’s bedroom which fire crews attended. The staff team did not always have mechanisms in place to support people with alcohol issues. A number of people commented on issues with some individuals who had been drinking alcohol. One person said, “Some of the lads are trouble, it’s getting worse.”

The staff team had not always worked with people to understand and manage risks. One person said, “No discussion about risk.” This was because there was often a lack of written guidance for staff, and they were not always knowledgeable about risks, including in relation to alcohol abuse. Staff felt the systems to share information where people’s needs had changed could be improved. Where people had equipment in place to manage risks to their skin integrity there was insufficient guidance for staff, including what setting specialist mattresses should be placed on, and this information was not monitored.

The provider had not always detected and controlled potential risks in the environment. They had not always maintained a comfortable, tidy, clean and homely environment for people to live. The provider had spent significant sums of money on improving boiler systems and installing a new lift, but further work was still required. This included the need for a new bathroom, further updates in decoration and repair, and updates to general safety checks which had not identified, for example, wardrobes not being attached to the wall and loose wiring in one part of the building. People did not always sign in and out of the building when they left which posed a risk should an emergency evacuation occur. The management team were going to address this immediately.

The provider took steps to ensure there were enough staff. However, it was difficult to establish if staff were suitably qualified and skilled due to poor record keeping. Staff had not always had regular and effective support, including supervision and appraisal sessions. Staff told us the new management team were now listening, and they felt more supported. Recruitment practices were not always meeting requirements. For example, staff records needed to include information about gaps in employment not accounted for on application forms, DBS best practice guidance was not always followed, and interview records were not always in place. The management team were going to address this, and a new administrator had been appointed to support this work.

The provider had not assessed and managed the risk of infection. Some areas within the service were dirty and poorly maintained, including people’s bedrooms. Some bedding was dirty and flooring unclean. Bedrooms often contained dirty furniture and food debris. Outside storage spaces contained clutter and items not suitable for this type of storage environment. This included unused incontinence pads, which the manager agreed, now needed to be disposed of due to the place in which they had been stored.

The provider did not make sure that medicines and treatments were safe and met people’s needs. We found a range of concerns, including ‘as required’ medicines protocols not in place. These protocols provide staff with information on when and how to administer these types of medicines which are often for pain relief. When some ‘as required’ medicines were administered the effectiveness was not always recorded or monitored. Topical cream charts were not always in place to record when staff had applied these. Medicines administration records were not always legible and completed fully. They had numerous entries scratched out and outcomes of some medicines administered were not always completed. Medicines which were to be given before food, had not always been given in a timely manner. We were not assured people were receiving their medicines as prescribed.