Westholme Care Home Limited

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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 63 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There was an up-to-date policy to support staff to report incidents. Staff recorded information on the electronic care record system and managers monitored this. The registered manager had a system to review incidents at regular intervals to make sure improvements and changes could be made where required.

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.

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.

Staff completed safeguarding training and knew how to report concerns. The registered manager maintained a safeguarding folder to monitor referrals and made sure recommendations from safeguarding investigations were implemented. There was relevant information easily accessible to staff. The registered manager applied to the local authority if anyone was at risk of being deprived of their liberty. People said they felt safe. One person said, “I feel perfectly safe, I sometimes feel safer here than I did at home.”

Staff provided care to meet people’s needs however some written documents did not always reflect up to date information.

There were inconsistencies in some written information about people’s risks. One person’s nutrition and hydration information did not contain sufficient information about their needs and differed from what staff told us. For someone that had diabetes, there was information missing in the care plan to guide staff about what signs and symptoms to be aware of to help them identify any risks. The registered manager reviewed both people’s care records following our feedback and made referrals to the right health professionals.

For most people, risk assessments were up to date and were reviewed monthly.

The provider did not always detect and control potential risks in the environment.

The provider had not organised an adequate risk assessment regarding fire safety following the advice of the fire service in 2024. We found that not all staff would know how to open the emergency fire exit on the top floor. The registered manager put measures in place to address after we fed this back.

Due to the age of the building some areas had uneven flooring which could cause a falls risk; however, the provider tried to minimise the risk by applying hazard tape.

There was a maintenance management system, and we saw that some items needed to be replaced or fixed such as the door handle in the conservatory, which was on the list to be addressed.

Health and safety checks had been undertaken including gas and electrical safety, and water safety.

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 were recruited using safe processes including those recruited via the government overseas staff sponsorship scheme. Training compliance rates were high, and staff told us they completed learning and development to support their roles. Although there were enough staff to meet people’s needs, some times of the day were challenging as people required 2 members of staff to meet their mobility needs, and staff were responsible for administering people’s medicines and completing laundry tasks. People said it did not usually take staff too long to answer their call bells, but it depended on how busy they were.

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

Some areas of the home needed to be cleaned such as the rugs and skirting boards. Some staff did not adhere to guidance regarding bare below the elbows. The laundry environment required cleaning and tidying and the registered manager told us this would be addressed immediately.

There were cleaning schedules in place and the people’s bedrooms were cleaned every day. The managers completed hand hygiene audits, and we observed staff wearing appropriate protective clothing such as aprons and gloves. People commented their rooms were clean and tidy.

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

We found some medicines which had expired, or no longer in use had not been disposed of according to guidance. Staff did not monitor the temperature of the medicine’s storage room or fridge to make sure medicines were stored safely.

Although there was guidance for medicines that were administered ‘as and when required’, for some people these medicines were being given regularly, meaning a GP review could be required to make sure guidance was correct. Staff were not always recording where they applied a person’s skin patch to make sure the patch was rotated to reduce the risk of skin irritation. We found no impact and all issues were addressed promptly after we fed this back.

There was adequate guidance about people’s prescribed medicines and staff signed to say they administered medicines according to people’s prescriptions. Staff completed medicines training relevant to their role.