Well Springs Nursing 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 the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment and safeguarding.
 

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.

The provider did not always have a proactive culture of safety based. Staff did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Whilst the provider had systems in place to monitor incidents, accidents and behavioural risks, these were not always effective at ensuring risks were consistently mitigated. We found repeated incidents of people attempting to leave, with limited evidence that identified strategies within care plans were being implemented or reviewed for effectiveness. There were also missed opportunities to strengthen falls prevention measures and review the effectiveness of actions taken following incidents, including head injuries. This meant lessons learned and risk reduction measures were not always translated into practice.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Pre-admission assessments were completed to help ensure people's needs were understood before they moved into the service. We also saw evidence of staff working proactively with external healthcare professionals and advocating on people's behalf to support access to healthcare services and continuity of care.

However, we found key admission documentation for 1 recently admitted person remained incomplete 6 days after they moved into the service. Whilst information about the person's needs had been gathered through the pre-admission process, the provider's policy did not clearly state the expected timeframe for completing admission documentation. This meant documentation may not always be completed consistently following admission.

Following the assessment, the provider updated its admissions policy to specify that care plans should be completed within 48 hours of admission.

The provider's systems for safeguarding oversight were not always effective.

We found several unexplained injuries had been recorded, including bruising and a cut, but there was no evidence these had been fully investigated, considered under safeguarding procedures, or reviewed for themes and trends across the service. The registered manager told us there was no formal process for analysing unexplained injuries, which meant the provider could not demonstrate potential safeguarding risks had been appropriately explored or that learning had been used to reduce the risk of recurrence.

However, staff understood how to recognise and report safeguarding concerns, and safeguarding incidents had been appropriately referred and notified where required. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that a DoLS tracker was in place, and all but 1 person whose records we reviewed had a recorded mental capacity assessment and best interest decision relating to restrictions in place. The provider responded immediately and ensured the outstanding paperwork was completed.
 

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

We found 1 person had been admitted to the service without risk assessments in place to guide staff on how to provide safe care and treatment. Some risks to people identified in their care records were not always effectively managed. For example, 1 person had identified strategies to reduce the risk of them attempting to leave the service, but these had not been evidenced as implemented. Opportunities to review and strengthen risk management had also been missed, including for a person who experienced recurring falls. Records also showed some people had not consistently received care in line with their assessed needs relating to repositioning, continence support, bowel monitoring and prescribed 'when required' (PRN) medicines. This meant the provider could not always demonstrate risks to people's health, safety and wellbeing were effectively managed.
 

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.

The provider's systems for assessing and managing environmental risks were not always effective. We found 1 person did not have a Personal Emergency Evacuation Plan (PEEP) in place, and there were multiple discrepancies within evacuation records which meant the provider could not be assured emergency information was accurate and up to date.
We also found integral bed rails were fitted to people's beds regardless of whether required them, and the provider could not demonstrate their use was always based on an assessment of need and risk.
However, the service was clean, well maintained and had up-to-date servicing and safety checks for the equipment and premises in place.
 

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider had effective systems in place to ensure there were sufficient numbers of suitably recruited staff to meet people's needs safely. Appropriate pre-employment checks had been completed, staff received regular supervision and support, and training compliance was maintained at a good level. Staff were visible throughout the service, and staff told us there were sufficient staff to meet people's current assessed needs.
 

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 generally maintained effective infection prevention and control systems. The service was visibly clean, staff followed appropriate infection prevention and control procedures, and regular audits and external reviews were completed to monitor standards. However, we found hoist slings were used by multiple people rather than being allocated for individual use, which increased the risk of cross-contamination. The provider responded promptly to our findings and took action to address this. Overall, people were protected by systems which supported good infection prevention and control practices.
 

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

We identified several concerns relating to the administration, monitoring and governance of medicines, including a lack of competency assessments for staff administering medicines. There were missing or insufficient ‘when required’ (PRN) protocols, gaps in the monitoring of high-risk medicines, incorrect patch rotation, poor documentation relating to creams and thickening agents, and a person admitted to the service without all relevant medication documentation or medicines care plan in place. These issues meant the provider could not be assured medicines were always managed safely and in line with people's needs.
However, medicines were generally stored securely, and systems were in place to support the ordering, storage and administration of medicines.

The provider was responsive to the assessment feedback and had already begun taking action to address some of these shortfalls.