Widecombe 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 inadequate. 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 at the service.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

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. For example, we found sluice rooms unlocked, putting people at risk. The importance of locking the sluice door after use was shared by the registered manager at team meetings and documented in meeting minutes, however the sluice doors was still not locked by staff. This was not effective in ensuring peoples safety.

The provider responded swiftly when these concerns were brought to their attention and changed the locking system to an effective system for staff to implement.

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.

People were supported to see their GP. Staff told us the GP was very supportive. For example, when people required Speech and Language Team (SALT) these were supported by the GP and the appropriate safe pathway of care was met.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they were happy at Widecombe Nursing Home. A person told us, “I am happy here.” A relative told us, “[Person] is safe. They are unable to call staff on their own. However, there is always someone available to assist them.”

Staff received safeguarding training and demonstrated a clear understanding of the procedures for reporting concerns. Deprivation of Liberty Safeguards (DoLS) authorisations were sought when required to lawfully deprive a person of their liberty.

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. For example, we found some incidents which had not been reviewed by management, potentially missing opportunities to review trends and actions taken by staff.

The registered manager promptly reviewed the incident system and provided refresher training to staff.

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.

Water temperatures were checked monthly; however, we identified 3 areas which were accessible by people, with access to water at a temperature above 44 degrees. This put people at risk of scalding from hot water. We found a person’s radiator cover broken with an exposed hot water pipe, which put people at risk.

We raised our concerns with the provider; they acted promptly to address this during the assessment.

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. Staff told us they felt there were sufficient staff on duty to meet people’s needs.

A relative said, “The quality of service is very good. The care workers are very caring.”

Staff had received appropriate training to carry out their roles in supporting people at Widecombe Nursing home. We observed staff working as a team to support people’s needs.

The provider did not always assess or manage the risk of infection. We observed some chairs in people’s rooms were damaged and stained and a damaged over bed table, which was still in use. The damaged furniture could no longer be cleaned properly.

The provider informed us that they were in the process of replacing damaged furniture, having already replaced several pieces of furniture at the service.

Staff had been trained in infection control, and we observed staff using appropriate Personal Protective Equipment (PPE) when supporting people.

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. Medicines were not always administered as directed. For example, an agreed covert medication plan for a person was not followed as instructed and gaps in monitoring syringe changes for people’s PEG (Percutaneous Endoscopic Gastrostomy) water flushes. Whilst we found this had not resulted in harm, poor understanding and documentation can increase risk to people. The registered manager responded effectively when these concerns were brought to their attention, carrying out an investigation and providing refresher training for staff.