Whetstone Grange

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.

During this inspection we identified a breach in regulation in relation to safe care and treatment.

This service scored 47 (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 and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Prior to our inspection CQC received an anonymous concern stating that staff were moving people without footrests on their wheelchairs, putting them at risk of injury. When we inspected, we observed this happening. Some of the people being moved in this way had risk assessments saying this was acceptable, but others did not.

Staff said the provider had already told them not to move people without footrests unless there was a risk assessment stating otherwise. However, some staff had continued this unsafe practice. This showed that staff had not always listened to concerns about safety and lessons had not been learnt.

The deputy manager said they had set up a messaging platform for staff and in future lessons learnt would be shared on this. When we returned for the second day of our inspection, moving and handling was carried out safely and staff ensured people who needed footrests on their wheelchairs were using them.

The provider did not always work well with people and partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

During our inspection a new person was admitted to the service. Their documentation, consisting of a pre-admission assessment, was incomplete with multiple areas listed as ‘TBC’ (to be confirmed) including information about key contacts, consent, and health.

This meant the service had not worked with the person or those close to them to establish their needs and plan of care prior to admission. This should have been done to eliminate any risks and to ensure the person received continuity of care from the point of admission.

Managers said people were assessed prior to admission by the provider’s admissions manager and/or a senior member of staff at Whetstone Grange. They said they would be informed of the improvements needed.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them 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 bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Staff had not always followed the provider’s policies and procedures when safeguarding incidents occurred. In July 2025 there were 5 incidents of ‘aggression’ involving people using the service. None of these were reported to the local authority or CQC. Managers said this was due to a manager not understanding what constituted a ‘safeguarding’ and had been addressed. Since then. safeguarding had been properly reported.

People and relatives said people were safe at the service. A person said, “I feel safe here because there’s people here all the while. I didn’t feel safe at home.” Another person said they felt safe because staff were close by and they always had their walking frame with them.

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.

We found instances where people at the service were at risk.

We saw 5 different people being moved in wheelchairs with no footrests, or with both their feet not securely on the footrests. Only 2 of these people had risk assessments to say this was acceptable due to their individual needs. The other 3 did not and were at risk of injury from their feet dragging on the ground or being caught under the wheels.

This was not a new issue. Prior to our inspection, we received information that staff were moving people without footrests on their wheelchairs. A relative told us they had recently found their family member in a wheelchair with no footrest and their legs ‘hanging down’.

A staff member expressed frustration about the footrest situation. They told us, “Sometimes I come to work in the morning and find someone took the footrests off [wheelchairs]. Why? We have to search for them, they’re usually under the stairs or in bedrooms.”

Another staff member did not understand the importance of footrests and said, “I would rather the person got to the loo in time even if it means not using footrests.” We checked training records, and this staff member was not on it so there was no evidence on them having moving and handling training.

A person’s bedsheets did not fit their bed resulting in their feet laying directly on the plastic mattress cover. This put the person at risk of skin damage.

A person was admitted to the service with limited information about how they might be at risk. For example, it was not known if they had any allergies, what their food preferences and texture requirements were, or if they were at risk of choking. Despite this staff offered them sandwiches on their arrival without knowing if they were any risks regarding their nutrition.

These issues were reported to the provider and managers at the service who said they would urgently address them.

People mostly had risk assessments in place for areas where they might be at risk including personal care, positive behaviour support, and continence. Those we checked were detailed and included the information staff needed to keep people safe.

A relative said their family member was safe because there was a sensor mat by their bed, so staff were alerted if the person got up in the night.

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.

Although the provider had refurbished parts of the premises, there were still risks present. There was exposed pipework in some bedrooms/toilets/bathrooms that could put people at risk of burns. A fire door on a person’s bedroom was propped open with a chair. A staff member went to prop open another fire door on a lounge but stopped when we queried this. There was a hole in the footboard of a person’s bed.

We reported these issues to the provider who said they would be promptly addressed. The bed with a damaged footboard was replaced the same day.

Staff said the premises were better and safer than they had ever been. In the last year the provider had fitted window restrictors, provided radiator covers and a working bathroom, and created a safe outdoor space for people.

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, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff had not had the training they needed to meet the care needs of all the people using the service. For example, people with sensory loss and Parkinson’s disease were using the service. However, staff had not had training in these areas.

In addition, the service’s training records showed other staff training courses had not been completed by all the staff they were intended for. For example, only 8% of the staff had competed diabetes training, and only 10% had completed positive behaviour support training. The was despite people with diabetes and behaviour support needs using the service.

The provider said their training and development team would address these shortfalls and ensure all staff had the training they needed to provide safe and effective care and support to all the people using the service.

Staff had not received regular supervisions and appraisals. The provider’s policy stated they should have at least 6 supervisions and 1 appraisal each year. However, records showed 19 staff members had had no supervisions or appraisals in the last 6 months. Managers said this was being addressed.

Staffing levels were satisfactory. People’s needs were promptly met and there were enough staff on duty to support people and interact with them. During lunch we observed staff assisting people with their meals and conversing with them in an unhurried manner. A relative said, “Overall it seems fine. There’s enough staff milling around.”

The provider used a dependency tool to calculate the number of staff required by assessing people’s individual care needs and converting those needs into required staff hours and skills. This helped to ensure the service was staffed appropriately.

Staff were safely recruited with checks carried out before they started work to ensure only staff who were safe to work with people who use care services were employed.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Some improvements were needed to minimise the risk of infection at the service.

A person’s bedsheets did not fit their bed resulting in their lower legs (which were weeping) and feet laying directly on the plastic mattress cover. This prevented proper air circulation and was an uncomfortable and unhygienic sleep surface.

A person’s room smelt strongly of urine. There was urine in the bedpan which staff were meant to empty regularly. The person told us staff emptied the bedpan but did not wash it our leaving the person to clean it themselves with wet wipes.

A member of staff was wearing ‘croc’ shoes with a pattern of holes in the upper. These shoes are not suitable in care settings because they expose the feet to contaminants, which could lead to infections and other health issues. This is especially true for employees who work in areas where they encounter bodily fluids or other hazardous substances. We discussed this with managers who said staff had already been told not to wear this type of shoes and they would be reminded of this. However, when we returned for the second day of our inspection a member of staff was still wearing ‘crocs’.

Managers and the provider said these issues would be addressed.

There was a malodour in the laundry room. The provider said this was probably the drains and it was being dealt with by their property department.

Other areas of the service were mostly cleaned to a good standard. Kitchen and cleaning staff told us managers were carrying out more checks and cleaning standards had improved

The provider did not always make sure that medicines and treatments were stored safely and met people’s needs, capacities and preferences.

Medicines were not stored safely. Records from the months of July and August 2025 showed the temperature in the medicines room exceeding 25 degrees on over 30 occasions. This is above safe storage guidance (which recommends storage temperatures of between 5 and 25 degrees centigrade), as set out in the provider’s medicines policy. Temperatures above 25°C can degrade some medicines, reducing their therapeutic effectiveness

There was no other effective mitigation in place. The provider’s medicines policy said that if temperatures could not be controlled ‘an alternative storage area will be found’. This had not happened. The form used to records temperatures directed staff to contact the community pharmacist for advice if temperatures deviated from the recommended minimum/maximum. This had also not been done.

We brought this issue to the attention of the provider and a senior staff member responsible for medicines. The provider said they had ordered an air conditioning unit, but it had yet to be delivered. They said they would chase up this order. The senior staff member contacted the community pharmacist for advice with the aim of ensuring medicines were stored safely in future.

A person was prescribed a PRN (as required) medicines for ‘agitation’. There was no PRN protocol for this medicine in the medicines room PRN folder. There was no record of the person being administered this medicine, but when we checked stocks one of the tablets was missing from the packet. This put the person at risk as it was not clear whether they had had this medicine or not. We reported this issue to the provider and managers who said they would investigate what had happened.

People and relatives had no concerns about how medicines were administered at the service. A person said, “The medication has improved. I get it on time and regularly.” Another person told us they took their medicines twice a day in their room. They commented “Staff won’t leave unless they see it go down.”

Staff were trained in the safe administration of medicines and had competency checks to ensure they understood their training. GPs carried out regular reviews to ensure people’s medicines were suitable for their needs.