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 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 aspects of the service were not safe and there was limited assurance about safety. There was an increased risk people could be harmed.

The provider was in breach of legal regulation 12 in relation to people’s safe care and treatment including the ways people’s medicines were managed 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.

The recording of accidents and incidents had been an ongoing concern in relation to risk management. Despite these issues being highlighted to the provider through previous assessments, they have failed to address them. There were inconsistencies in how incidents and accidents were recorded. Additionally, lessons learned were not always documented, and where they were, it was unclear how this information was shared with the staff team.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Accidents and incidents were not always fully investigated to understand how injuries happened. When staff completed incident forms, they often lacked detail and were not always completed in full. We found examples where no investigation had taken place, even though injuries had occurred.

Our review of accident and incident records showed, in one month, 14 different people in the service experienced a skin tear. We identified 2 incidents that should have triggered safeguarding action, but no action was taken because the registered manager was not made aware of them. This was due to inconsistent recording of information.

As a result of our findings, we made 1 safeguarding referral involving 4 people and raised 2 further concerns with the local authority.

There were inconsistencies in the information recorded within care plans and risk assessments. For example, one person’s risk assessment stated they required the use of a call bell; however, their care plan indicated they were unable to use a call bell. During observations, we noted this person did not have a call bell in place. Therefore, it is unclear what the actual risk was and whether not having a call bell placed the person at risk.

We identified one person’s fall risk assessment recorded them as ‘medium risk’ in one section and ‘high risk’ in another, creating further inconsistency.

Sensor mats were in place for people who required them to reduce risks; however, we found numerous mats were not working. Some people had fallen when the mats were not functioning, which placed them at risk because staff could not determine how long the person had been on the floor. We raised this with the provider during both site visits and shared this information with the local authority.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider failed to ensure there was enough suitably qualified staff providing support. Some care staff had not received training in relation to specific medical conditions including diabetes and epilepsy. Care staff had not received any training regarding catheter management yet were responsible for delivering some aspects of this care.

Care staff were applying topical creams without having undertaken any medication awareness training. Whilst some nursing staff had received additional training to enable them to support people safely, there were times when no staff members on shift had received training in relation to syringe drivers. There was no assurance that people who were prescribed anticipatory medicines and were in the final stages of life would be given their medicines in a timely manner because records showed there were insufficient staff trained.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Following previous inspections, the provider had introduced recording systems to show medicines and topical preparations, such as creams, were being given as prescribed and in line with manufacturers guidance. However, at this assessment, we saw the records were not always being completed, therefore, the provider continued to not be assured medicines were being given safely and topical preparations were being applied as prescribed.

When people were prescribed a medicine that required a specified time interval between doses, for example, paracetamol, the required time interval was not always observed. We found one person was given their paracetamol doses too close together, which placed them at risk of harm. The provider had not identified this; however, they took the appropriate action once they were made aware.

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 ‘when required’ medicines there was not always person-centred information to support staff to safely administer the medicines. This meant people might not get the ‘when required’ medicine when they needed it. We 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.

The provider provided information that showed not all staff who were administering medicines, had completed medicines training. Competency assessments for tasks related to medicines administration and application of topical preparations such as creams had not been completed.

Medicine audits were carried out regularly; however, they were not effective in identifying medicines related issues occurring and had not identified the concerns we found on inspection.