West Hill 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 requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment and safeguarding service users from abuse and improper treatment.

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 provider did not have a proactive and positive culture of safety based on openness and honesty. Staff did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. The learning culture at the home had deteriorated rather than improved following the previous inspection. People had not always benefitted from a service that learned lessons from accidents and incidents.

There were systems in place to record and act upon incidents and accidents. However, systems were not effective as incidents were not always reported in a timely way by staff. For example, one person had unidentified bruising. There was a delay in the incident being reported to the manager. The registered manager told us, “After each accident or incident, there is a ‘lesson learned’ with the staff. We discuss concerns in handover every day, there is a daily clinical meeting where we review current risks, and a daily staff huddle to pick up any emerging issues. Because scrutiny is several times daily, the reporting structure is much clearer for staff, and the number of incidents has reduced such as falls and skin tears.” However, the investigation into the unidentified bruises did not lead to timely improvements regarding reporting as later in the month there was another incident which staff did not report until 5 days later. This delayed the registered managers’ ability to take action to protect people and left people at risk of harm.

When people were upset or distressed staff used ABC forms to monitor any incidents. The aim of ABC charts is to assist staff to understand the triggers and patterns for incidents and identify more effective strategies to support the person. ABC charts were poorly completed and did not support staff with this aim and learning lessons. Details were lacking. For example, some charts did not include information on who was involved so the registered manager could analyse if this had an impact. There was little information about the triggers to some incidents or what had worked to calm the person down other than staff’ provided reassurance’.

Some relatives told us they were kept well informed when there were incidents. However, some relatives felt less informed. For example, one relative told us following incidents they did not always get a clear explanation of what had occurred.

The provider did not work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage people’s safety. They did not always ensure there was continuity of care.

Guidance from health and social care providers was not always followed. For example, guidance from the speech and language team regarding how to support people at risk of choking was not always followed by staff. This increased the risk of people choking or aspirating when eating and drinking.

Feedback from health care professionals was mixed. Some health and social care professionals were not positive about how well staff engaged with them. Another professional said, “There seems to be a reasonably high staff turnover, and the fact that I speak to different staff members every time I visit does not encourage continuity of care generally.” However, another health care professional told us, “The care and nursing staff on each floor are always happy to provide information on behalf of the people who are referred to us.”

The provider did not work well with people to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from abuse, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Staff continued not to identify and report all safeguarding concerns. Staff had undertaken training in safeguarding from abuse but had not always recognised when abuse was occurring and acted to protect people. For example, staff were using a special chair to restrict one person’s movement and prevent them from getting up. Staff had not identified this was a form of restraint and that using restraint without undertaking the appropriate steps was a safeguarding concern. Steps had not been taken to assure using the chair was a proportionate response to any risk of harm. Following our visit the registered manager re-assessed the person and identified they did not need this chair. Without reporting, investigating or reviewing safeguarding information, the provider could not assure themselves that people were appropriately protected from the risk of abuse.

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

Although we observed some staff following good practices to keep people safe, we also observed concerns. For example, staff gave a person a banana, and the person proceeded to eat the skin rather than the fruit. Staff said the person had done this before, however, adjustments had not been made, such as peeling the fruit, to ensure the person was safe. We had to intervene when another person was being supported to eat. Staff had not taken sufficient steps to reduce their risk of choking before supporting them to eat.

One person was at risk from pressure ulcers. They were supported to remain in a chair and were there for prolonged periods without changing position. There was no plan on how staff were to support the person to remain safe from the risk of pressure sores.

Records showed there were significant gaps between the support provided to some people for areas such as continence care. This meant there was an increased risk the person could develop moisture legions or skin infections.

Guidance for staff was not always in place to ensure staff had the information they needed. For example, one person with a diagnosis of Parkinson’s Disease had no care plan in place to aid staff to safely manage their condition. Another person had diabetes, and a high blood sugar reading, there was no information in their care plan about how they might present if their blood sugar was too high and staff needed to act. One person’s care plan did not include any details about how being NIL by mouth impacted on their dental care so staff knew how to keep them safe from any swallowing risks. Following our inspection, the provider sent evidence of the immediate actions they had taken to update people’s care plans. However, action had not been taken prior to the inspection. There was a lack of guidance for staff with regards to how to hoist several people. This meant there was a risk new and agency staff would not know how to support people safely.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

One person’s care plan stated they had a history of attempting to ingest chemicals, plastics etc, and “walked with purpose”, however, there was no risk assessment in place regarding this. We observed cleaning cupboards were unlocked at lunchtime and in the afternoon. The small kitchen on floor 2 had a cupboard which was unlocked and contained cleaning chemicals, washing up liquid and an antibacterial cleaner. These would be harmful if ingested. We also observed medicines used to thicken liquids were also not kept secure, these medicines can cause a choking risk if ingested. Once inspectors highlighted this concern to staff the items were removed.

People’s personal emergency evacuation plans (PEEPS) were limited in detail and not always in date. For example, one person who required a full hoist for all transfers had recorded in their PEEP they used a stand aid. While their PEEP stated they could be both verbally and physically distressed, there was no guidance on how staff should manage their distress during an evacuation. There was also a lack of guidance regarding what support people would need to when at the evacuation point.

Staff told us they knew where the muster stations were and had undertaken fire training. Fire alarm tests were taking place. However, the provider had not taken sufficient action to ensure the staff on shift could evacuate people in a reasonable amount of time in the event of an emergency.

People and their relatives told us they were happy with the environment. However, more than one person told us their bed was uncomfortable. Essential servicing and maintenance of the gas, electric, lift, fire alarm system, emergency lights, and moving and handling equipment had taken place. Radiators were covered. There were window restrictors to all windows. The corridors and lounges were light, airy and unobstructed. Toilets and bathrooms were clean, sanitised and fresh with pull cord alarms in accessible reach.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support and development. They did not always work together well to provide safe care that met people’s individual needs.

Some training had not been provided in a timely way. For example, one member of staff had repeatedly requested manual handling training but was not provided this for some months after they started in post despite supporting people with manual handling. Not all staff had completed training in catheter care to ensure they knew how to provide this support safely and effectively. Staff were providing people with catheter support, however, only senior staff and nurses had any training to do so. We’d identified concerns which indicated staff training had not led to staff providing effective support. For example, we had observed unsafe and undignified care during the inspection. Staff continued to fail to identify safeguarding concerns.

Staff gave mixed views about whether there were enough staff on duty to provide safe care. One staff member told us, “There are not enough staff on floors 2 and 3, it’s too stretched for the needs of the residents.” The provider told us they used a dependency tool to calculate staffing levels.

Feedback from relatives was also mixed. Most people and their relatives were positive about staffing levels. One relative told us, “It always feels like there are a sufficient amount of staff on the floor.” However, another relative said, “Sometimes it seems fraught.”

Staff had been recruited safely and received supervision.

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.

The provider assessed and managed the risk of infection. Regular infection control audits were completed, and we observed housekeeping staff working throughout the day. People’s rooms were clean and tidy, and the environment was clean and smelt fresh. Staff were seen wearing appropriate personal protective equipment (PPE) when carrying out particular tasks.

People were complimentary about the cleanliness of the home. One person told us, “It’s lovely and clean…I’ve never had any cause to complain about anything like that.” The laundry room was well organised. A staff member told us, “Care homes and nursing homes can easily spread infections. We have to make sure we maintain best personal hygiene practices like handwashing, wearing PPE and safely disposing of waste.”

The provider did not make sure medicines were always managed safely and inline with best practice guidance. Systems to manage medicines was not safe.

Staff had identified concerns with one person medicines in that they were taking two medicines which could interact with each other in an unsafe way. The staff member withheld one of the medicines to reduce the risk. However, they had not handed this concern over to other staff and both medicines were given the next day. This put the person at increased risk of harm.

We reviewed the electronic medicine records for a range of people and found several concerns. For example, one medicine had not been checked in for a week. This medicine should have been documented in a book to record it was onsite and was not. This increased the risk of the medicine being removed and used for improper purposes.

Several people’s medications were being crushed without any direction to crush on the pharmacy label. We were not assured staff had checked it was safe to crush these medicines. Not all medicines can be crushed as doing so could affect how the medicine works or how quickly it is absorbed.

Some people were prescribed medicines for distress. While they both had “as and when required” (PRN) protocols in place for this medication, we found the medicine had been given repeatedly without a detailed rationale as to why, or what actions taken by staff to mitigate distress behaviours prior to administering this medication. This increased the risk the medicine could be given more often than needed as appropriate monitoring was not in place.

Medicines used to thicken fluids were being shared amongst people. These medicines are prescribed and should not be shared. Some medicines were not dated when they were opened so staff could tell when the medicine was no longer suitable to be used.

There was agreements for several people who required some medication to be administered covertly, but without direction as to which medicines needed to be administered covertly. Where medicines are given covertly the medicines need to be listed. People’s medicine support needs were assessed, and most people were happy with the support they received. However, one person told us they would like to do more of their medicines themselves but were not supported to do so. Another person told us they did not want to be woken up for pain medication.

We raised these concerns with the management team on the day of inspection. Following our inspection, the provider sent evidence of the actions they had taken to address some of these concerns. However, concerns were not addressed prior to us identifying them.