Wythall Residential 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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 promote a learning culture as they sometimes missed opportunities to learn when things had gone wrong. The registered manager told us they had not received any complaints in the last 12 months; however, whilst relatives’ feedback was mostly positive, some feedback we received from them highlighted areas where the service could have reflected and improved practice. This meant the provider did not always embed learning or use it to drive ongoing improvement. The provider had a complaints and duty of candour policy in place, however, these required reviewing to ensure they aligned with best practice.The registered manager reviewed accidents and incidents and recorded follow up actions in a monthly report. They analysed this information to identify any patterns or trends.
 

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. Staff carried out pre admission assessments to ensure they understood people’s needs before they moved into the service. People had opportunities to try the service through respite stays or day visits before deciding to move in permanently, which helped support smoother transitions. Staff discussed new admissions and any changing needs during handover meetings to ensure everyone remained informed. Records showed staff made timely referrals to external partners when required, which supported continuity of care. The provider issued people with a Service User Guide, which gave information about the service, what people could expect, how to access support and how to raise a complaint.
 

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 and their relatives told us they felt safe in the service. One person told us, “I am happy and feel safe”. Relative’s comments included, “Safe, oh yes without a doubt.” and “I’m 100% happy with [Person’s name] care. I can honestly say if I had to go into a home, I’d choose to go there.” The service displayed clear information about abuse and how to raise concerns, which helped people and visitors understand how to seek help if they needed it. We checked whether the service was working within the principles of the Mental Capacity Act 2005 (MCA) and how they managed Deprivation of Liberty Safeguards (DoLS) within the service. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. We found people who did not have the capacity to agree to their care and treatment had the appropriate legal safeguards in place.
 

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Care records contained information on how to manage each person’s individual risks, and staff followed this guidance to keep people safe. Where people were at risk of developing skin damage records showed staff were providing regular pressure relief. However, we did identify gaps in 1 person’s records. People with swallowing difficulties had dysphagia passports in place, which clearly described the type of diet they required and how staff should support them to eat and drink safely. Where people were at risk of falls, steps were taken to reduce these. One relative told us, “There's a mat next to [Person’s name] bed that alarms when he treads on it.”

The provider mostly detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider had not considered risks associated with the use of emollient creams, particularly for people who smoked. No risk measures were in place to reduce the increased fire risk caused by emollient residue on clothing or bedding. This was fed back to the provider to act on. However, staff carried out regular checks on the environment and equipment, and external agencies completed routine inspections. Records showed when shortfalls were identified, staff updated them with evidence of the action taken to address the issues. Staff undertook regular fire checks and drills, and each person had a personal evacuation plan in place. The provider kept provisions on site should a fire occur, including an emergency bag containing essential items.

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 files did not contain all relevant information; however, these gaps related to historical files we had identified at our previous inspection. When we reviewed the file of a new member of staff recruited under the new manager, all documentation was in order. We discussed the shortfalls found in historic files, and the provider took action to address them, including introducing a checklist to strengthen oversight of recruitment records. Staff rotas were planned, and the registered manager monitored staff training to ensure compliance. Staff completed an induction programme that included e-learning, face to face training and shadowing experienced colleagues. We received mixed feedback from relatives regarding staffing levels. One relative said, “I don’t hear call bells ring for long. They’d [staff] ignore the front doorbell to see to the residents first,” while another told us, “No I don’t think there’s enough staff. You can ring the doorbell up to 3 times, but you know they [staff] are busy helping people.”

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 environment was clean and free from unpleasant odours, and a relative told us, “It’s very clean. The kitchen looks spotless too; I can see it through a window.” Staff had access to appropriate personal protective equipment (PPE), and hand washing signs were displayed in toilets and bathrooms to promote good hygiene. The provider had an infection prevention and control policy in place and completed regular audits to monitor compliance. We also noted improvements in the storage and labelling of food since our last inspection.

The provider did not always manage medicines safely or in line with best practice. Controlled drugs were not documented or stored appropriately, and the provider had not completed risk assessments for the use of emollient creams. The provider did not have a process in place for identifying, reporting, reviewing and learning from medicines errors. Medicines management could be further strengthened by ensuring guidance for people’s prescribed ‘as required’ medicines was clear and recording on medicines administration records was fully completed. We discussed these issues with the provider, who took immediate action during our assessment to address them. However, we did observe areas of good practice. We found guidance on the administration of covert medicines was available to staff and regularly reviewed by the pharmacist. Regular medicines audits were completed, balances recorded on medicines administration records were accurate, and staff had received medicines training with their competencies regularly assessed.