Welshwood Manor

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 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 the premises.

This service scored 31 (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. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The culture within the home was not always focused on safety and learning from incidents that had occurred. For example, incidents and accidents had not been effectively and robustly reflected upon and used to drive improvement. This meant these were not analysed consistently for patterns and trends to mitigate future risks to people.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Care planning and risk assessment processes to maintain and monitor safe systems of care were not sufficient and not all care plans and risk assessments were up to date to inform staff how to meet individual needs-. Care records did not include important information and did not always contain accurate or sufficiently detailed information about people’s care needs or risks. For example, in relation to diabetes care.

People were not always protected from the risk of abuse and harm. Not all safeguarding concerns had been discussed with, or referred to, the Local Authority Safeguarding Team. This meant there was not always independent oversight to ensure people were fully protected. The provider was not clear on safeguarding processes and had not taken correct action when a safeguarding allegation was made. The provider did not have the knowledge and skills to oversee the service safely in the absence of a service manager and we found examples where the provider had neglected their duties. This placed people living at the service at significant risk of experiencing harm and abuse.

At the time of our inspection there was an open local authority safeguarding investigation. Systems in place were not effective at ensuring people were protected from abuse and neglect. Incidents were not reviewed, and safeguarding concerns were not always recorded.

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

The provider failed to manage risks effectively to ensure people received safe care.We found a failure to take adequate steps to address concerns relating to the management and mitigation of risks meant people were exposed to the risk of avoidable harm.

Some people either already had or were at risk of developing a pressure ulcer. There were inconsistencies in the care records. For example, for one person their care plan stated they should be repositioned every 2 to 3 hours during the day and at night to help reduce the risk of further skin damage and to promote healing. This guidance was not being followed by staff and there were multiple gaps in the records. Records of staff supporting some people to reposition to reduce the risks of pressure ulcers worsening or developing did not evidence that those people were supported in line with their care plans. This placed people at risk of harm.

Staff did not consistently ensure people had the right equipment they needed. Inspectors observed during both site visits that some people, who were able to use one, did not have access to their call bell in their bedroom. This exposed people to risk of social isolation, unmet care and emotional needs and physical discomfort. A relative shared this concern saying, “[Family member had a fall a while back and their call [bell] was not within reach. I spoke to the home about this, and they reassured me it would be a priority however I frequently find [family member] in their chair and [the call bell] on the other side of the room.”

Where people had known health conditions which placed them at risk of harm, staff were not always provided with clear information and guidance on supporting people in relation to these and managing associated risks. Care plans lacked clear guidance for staff to follow about how the risk should be managed. For example, where peoplehad a health condition such as diabetes, there was no care plan in place on how to manage this.

Records did not always demonstrate people were appropriately supported to meet their oral hygiene needs. We found there were many people who needed staff to support them with their teeth brushing and/oral hygiene. We reviewed the records for two people and found only one person had a care plan to reflect a need for assistance to maintain oral hygiene and neither person had records to reflect any oral hygiene support had been provided over a 3-week period. Some relatives raised similar concerns with one relative telling us, “I have raised a concern about [family member’s] teeth. They are deteriorating and it is ending up in lots of fillings etc. I think further training may be required and/or make sure they guide [family member].” Another relative informed us of their concerns about a failure to provide support needed with oral care and the consequences of this. Government guidance states maintaining good oral health throughout life and into older age improves general health and wellbeing and plays an important part in helping people stayindependent.

During our inspection visit the personal emergency evacuation plan summary was incorrect and contained incorrect information. This place people at significant risk in the event of a fire or having to leave the building in an emergency. On arrival for the second day of our inspection the provider did not know which staff were in the building. This placed people and staff at significant risk of harm in the event of an emergency situation such as a fire.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.The provider had not ensured assessments of potential risks in the environment had been identified and reviewed to keep people safe. We found 3 windows on the first floor that did not have the appropriate restrictors fitted to keep people safe. Regulation applies to risks associated with windows and where there is a risk of falling from height, requires provision of devices that prevent the window opening too far. We told the provider to complete a full audit of all windows and ensure they were suitably secure.

We found the gas safety certificate was out of date and had expired which potentially placed people at risk of serious harm. We took immediate action to address this with the provider to ensure an appropriate response in a timely manner. The provider later told us they had located the gas safety certificate, however, there were no systems in place to ensure the servicing of appliances was recorded and certification kept safe. Despite multiple requests the provider did not send us a copy of the gas safety certificate.

The provider had failed to take timely action to address requirements following a Fire Officer’s inspection that was undertaken in February 2024. This required the provider to ensure there was an up-to-date plan to complete essential work to ensure the home would be safe in the event of a fire. During our inspection the provider was unable to locate a fire risk assessment and was unable to give a reason for the delay. The provider did make arrangements for the required work to be commenced when this was raised during the inspection however, despite multiple requests the provider did not send us a copy of this risk assessment or the schedule of recommended essential work to ensure the home was safe.

Risks to people from falls and potential injury had not been assessed with actions to guide staff in reducing the risk of harm. The service had staircases that were unrestricted and fully accessible, however, the risk of people accessing the stairs and their safety to do so had not been fully considered for all people. There were several people living in the home who were at risk of falls, and/or who lived with dementia who had unsupervised access to these stairs. We took immediate action and requested the provider assessed any potential risks to each individual person living at the service . Despite assurances that this had been completed, when we returned for our 3rd day of inspection, we found the risk assessments were not in place as stated.

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

Staffing levels were not managed safely. There was no system or method currently in place and being used to calculate safe staffing levels according to people's individual needs and risks. This meant there was no system to identify when staffing levels needed reviewing.

Feedback from people and relatives about staffing levels was not always positive. One person’s relative said, “Certainly at the weekend they seem to run on a skeleton…Often [family member] is not dressed and out of bed when I visit mid-morning. Often food trays are left in their room hours after mealtimes. On a couple of occasions when I’ve tried to find staff it's almost impossible. If any other [person] has a problem it seems to take up all available resources, surely that's a danger to the others. Having so few staff seems to leave them short of time for pleasant interactions that she used to have at her previous home.” Another relative commented, “I know a lot of time there are staff shortages due to staff vacancies, but I do feel that even if they were fully staffed, they could actually do with more staff. This is because my relative has had to wait for a bath because the staff are very busy and short staffed. This has also happened with other requests too.” A third relative informed us, “Unfortunately, four very good members of staff have left since [family member] joined and they haven’t been replaced. This has reduced my confidence in the home, and it has meant that there is more pressure on the staff who are there. It worries me that more may decide to leave. There is more dependence on agency staff and although I haven’t had any cause for concern with them, I don’t feel that they know [people] as well as permanent members of staff.”

We found there were insufficient staff to meet people’s assessed needs safely. Throughout our site visits, we saw staff were constantly busy, moving from task to task and did not have sufficient time to engage with people in a meaningful and person-centred way. Staff were found to be assisting people with care very early in the morning to suit staff and not people’s preferences. Some staff told us this was an expectation of senior staff in the service and related to insufficient staffing levels.

The local authority safeguarding team and CQC inspectors shared concerns about the staffing levels with the provider during the inspection and these were increased as a result of concerns shared with the provider. The provider did not understand the dependency tool the previous manager had used to assess staffing levels and the processes in place had not led to there being enough staff to support people prior to the inspection and needed to be improved.

A lack of professional boundaries and robust guidance placed people at risk of harm and abuse. The provider was permitting family members to work together delivering people's care without an appropriate risk assessment in place to explore the potential for concerns with this.

There were procedures to ensure the required checks were completed prior to staff commencing their employment. This included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions. Improvements were needed, however, to the on-boarding process for new staff with regards to references from previous employers as these were not in place for all staff.

The provider failed to ensure that people and staff were protected from the risk of infection, and best practice guidance was not always followed in relation to infection control, which placed people at an increased risk of catching and spreading infections. During the first inspection day visit there was no housekeeper on duty and areas of the care home were not clean. We observed, and relatives showed us, 3 toilets and commode chairs dirty with brown material which posed a risk of bacteria harbouring. One person told us, “The toilet is dirty; I use the mirror in there to do my eyes but it’s disgusting today. They don’t clean it like they should.”

We also found there were poor infection control procedures with regard to the workflow systems to ensure the separation of clean and dirty laundry meant there was an increased risk of cross-infection. We also found the provider had installed a domestic laundry machine in place of a commercial one and staff primarily used 20 degree washes. Only commercial laundry machines have the high temperature and disinfection cycles required for a care home. The provider’s failure to assess and mitigate risks associated with the management of people’s laundry and ensure staff followed best practice guidance in relation to infection prevention and control, placed people and staff at an increased risk of avoidable harm.

Risks associated with Legionella were not always mitigated, because unused water outlets were not always assessed and tested as required.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff had received training in medicines administration. However, we were not assured all staff had been regularly competency assessed by another suitability competent person. We noted some gaps in medication administration records which meant staff could not be assured medication had been administered as the prescribed intended, however, an audit of other medicine stocks against medication administration records [MAR] tallied.