Archived: Winsford Grange 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 inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation 12 in relation to people’s safe care and treatment, including the management of people’s medicines and regulation 13 in relation to safeguarding people from abuse.

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.

There was no clear oversight of accidents and incidents due to multiple systems of recordings. Information regarding accidents and incidents was not recorded appropriately and therefore there was a failure in identifying and mitigating risk which meant there was missed opportunities for lessons learnt. When learning was identified it was not clear how this was shared with the staff team.

The provider has not responded effectively to the findings from CQC inspections, missing opportunities to foster organizational commitment to continuous learning, open communication, and reflective practice to improve safety and outcomes, for people.

The provider did not always ensure that safe systems of care were in place, particularly in relation to care pathways and transitions between services. Care plans were inconsistent or lacked key information, which affected the provider’s ability to deliver safe and coordinated care. This was especially important when people moved between different teams or services where clear and up-to-date information had been vital. There was limited evidence that staff had shared important details effectively. For example, kitchen staff had been unaware of the dietary needs of two people, which could have placed them at risk. These issues showed that systems designed to support safe care, and smooth transitions had not always worked as intended.

The provider did not consistently adhere to the principles of the Mental Capacity Act. As a result, some people were subjected to restrictions without the appropriate legal authority. We found that people’s movements were limited using postural chairs and lap straps, and there was not always authorisation in place for these restrictions.

Additionally, we identified that accidents and incidents were not always thoroughly investigated to establish the facts regarding how people sustained injuries. Due to concerns having to be reviewed by the provider could have potentially caused a delay in them being submitted. Following our assessment, we submitted three Safeguarding referrals to the Local Authority safeguarding team this included 2 people living at the service who had sustained black eyes which at the time of the assessment had not been notified to the Local Authority

Some staff were aware of the whistleblowing policy and told us they would be confident in raising a concern if needed. Comments included: “I am aware of the whistleblowing policy and safeguarding. Safeguarding means protecting people from abuse or neglect.” However, one member of staff told us they were not aware of the whistleblowing policy. Training compliance for safeguarding was at 97%.

The provider did not always work well with people to understand and manage risks. We identified risks were not fully explored or managed in a way that reflected each person’s individual needs and preferences. As a result, care was not always planned or delivered in a way that was safe, encouraging, or helped them take part in the things that mattered most to them. Some peoples risk assessments contained contradictory information which could compromise the safety and consistency of care. A lack of thorough investigation into incidents and accidents meant that associated risks were not always fully assessed or understood, which limited the ability to put effective measures in place to reduce or prevent harm.

In some cases, although ways to reduce or manage risks had been identified, they were not consistently followed. One person sustained 3 separate injuries over the course of 4 months. These incidents were not thoroughly investigated, and the same assumption was made about the cause of each injury. After the first incident, an action was recommended to mitigate the risk; however, no action was taken. As a result, the person sustained two further injuries, again with the same assumption made about how they occurred.

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 had made improvements to the communal areas of the home; however, we observed that some people’s bedrooms required attention. Issues identified included stained ceilings, peeling paint, damaged walls, and in one-bedroom, broken tiles around the sink. The provider rectified the concern in relation to the sink following our assessment.

The provider did not consistently ensure that there were enough qualified, skilled, and experienced staff to meet people’s needs. Staff did not always receive adequate training to support people in their care, safely and effectively, including training specific to epilepsy, catheter care, medication awareness and diabetes. This included both clinical and non-clinical training and lack of competency assessments. We identified an incident in which a person required transfer to hospital for treatment because there was no qualified staff member on shift competent to meet their needs. This not only increases the risk from delays in treatment but puts them at further risk from hospital acquired infection. We reviewed documentation which evidenced the closure of one of the units was due to staffing difficulties, there was no evidence of best interest decision in relation to people moving rooms, some relatives raised concerns saying it was rushed and impacted their family member.

The provider did not assess or manage the risk of infection. They failed to detect and control the risk of it spreading. Whilst some improvements had been made, for example, the introduction of new chairs, we identified areas of the environment that required cleaning. This included people's bedrooms, dining room floors, some older chairs, ceiling and some damaged walls. Due to this damage, these areas could not be cleaned effectively. Upon reviewing documentation, we noted that numerous people had developed eye infections. A month later, this remained a concern. Training had been suggested as an action, but our review of training records identified whilst compliance in infection prevention and control training was 95%, no further training had been undertaken. Therefore, no action was taken to mitigate the risk of infections spreading. We observed one person using another person’s ‘in situ’ sling for a hoist. An ‘in situ’ sling is designed to be left in place under a person for an extended period. This was discussed with the management team however was not rectified. Using another person’s sling without proper cleaning or assessment presented an IPC risk. We also observed slings for one person being stored in another person’s bedroom.

We found medicines were not always available to be administered to people. During a four-week period, there was 22 occasions where people were not given their prescribed medicine, this included topical preparations such as creams. This placed people at risk of deteriorating health conditions and experiencing symptoms the medicines were prescribed to treat. We found one person had been given a medicine, on more than one occasion, that had expired several months previously, this placed them at risk of harm. This had not been identified by the service. When people had their medicines covertly, hidden in food or drink, the records and the discussions with staff showed this was not done in line with the provided guidance to safely administer the medicines. When people were prescribed ‘medicines’ to take only when needed, there was not always person-centred information to support staff to safely administer the medicines. This meant people might not get the prescribed dose of medicine when they needed it. We also found when people were prescribed a medicine with an option to give 1 or 2 tablets, there was not always information to support staff to know which dose to give. There was a risk people might not be given the most appropriate dose and their conditions including pain not managed. When people were prescribed topical preparations for example creams, the care plans were not always person centred and did not provide details of where to apply the creams. This meant there was a risk the creams would not be applied correctly. The recording of the application of creams did not always contain sufficient detail to show the creams had been applied as prescribed. When medicines related incidents occurred, we were not assured that they were investigated thoroughly, and lessons learnt shared with staff to prevent recurrence and improve the service. The service did complete audits; however, they had not identified the issues found during the assessment.