Wisteria House Residential Home - Rutland

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 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 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.

Incidents, accidents and falls were recorded, and staff took appropriate action such as contacting relatives or emergency services when required. However, these events were not consistently reported to all relevant external bodies such as the Care Quality Commission. There was no evidence of analysis or review of incidents, meaning trends and patterns were not identified and opportunities to reduce future risks were missed. Following the inspection, the management team retrospectively submitted the required notifications.

The provider had policies outlining the procedures to follow in the event of a fall, but these were not always adhered to and required documentation was not consistently completed. The registered manager told us the policies would be reviewed and updated, and that staff would be reminded of their responsibilities during team meetings.

Despite these shortfalls, people and their relatives reported that they felt safe in the care they received. One relative explained that they were consistently informed about any incidents involving their family member, adding, “I have no qualms about this at all.”

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 and their relatives told us they were involved in identifying the care and support needed, and where appropriate the provider took steps to support a smooth transition into the service. This included arranging visits so people could familiarise themselves with the environment. One person said, “I got my name down; this place has a good reputation here and I can see why.” A relative told us, “We brought [family member] here so they could see the home. The [registered manager] was brilliant, gave a guided tour and even asked if the room needed redecorating. [Family member] had no anxiety moving here and couldn’t wait.”

People had hospital packs in place, which were sent with them if they required hospital care. These contained key information, including communication needs, health conditions, mobility requirements and relevant medical details, to ensure external professionals had an accurate summary of the person’s needs.

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 were positive about the way their safety was considered. One person said, “Everyone (staff) looks after you I'm not alone I'm not doing as much now as I have help. I feel I am very lucky.” One relative told us, [Person] being here has taken the pressure off family, knowing they are safe and happy is enormous pressure off our shoulders.”

At the time of our inspection, one person had an application madefor a Deprivation of Liberty Safeguard (DoLS). This occurs when a person lacks capacity to consent to their care and treatment. It protects people who can’t protect themselves.

Safeguarding policies and procedures were in place.

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.

We found improvements were needed around the documentation relating to managing risks to people. For example, some people communicated their needs emotionally and physically. One person’s care records did not always detail strategies to help guide staff and provide support safely and consistently. Where people had become distressed staff had not always recorded how they supported the person. Records were not analysed to help understand potential triggers for people’s individual needs. However, staff we spoke with were able to advise how they would support specific individuals during periods of distress and the approaches they used.

Another person managed their own diabetes, but their records did not include information about the signs and symptoms staff should be aware of. During the inspection, the management team updated the diabetes care plan.

People and their relatives we spoke with raised no issues around the management of people’s health needs.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People told us that repairs within the home were completed quickly. One person said they only had to mention an issue and it was resolved straight away. They told us, “Maintenance just has to press a few buttons that I can’t manage, but they fix it straight away. They are amazing and can do anything, from the TV to the taps, they just gets on with it.” People were able to bring personal items from home, and these were safety‑tested before use. Records showed testing had been completed.

Regular environmental checks, including gas and electrical safety checks, were carried out to help keep people safe.

People had personal emergency evacuation plans (PEEPs), but these did not always reflect the actual support individuals would need in a fire. Accurate PEEPs are essential to ensure people can be evacuated safely. The registered manager assured us PEEPs would be reviewed and updated.

A fire risk assessment completed in September 2024 identified actions that had not been fully addressed, including maintenance of some fire doors and the need for staff to complete fire extinguisher training. The registered manager told us all fire door works had since been completed and signed off by an external contractor, although this had not been recorded. We checked a sample of doors, and these closed properly and had fire seals in place. The registered manager also confirmed that e‑learning and practical fire extinguisher training would be arranged in the coming months.

The provider did not always make sure staff had the required skills and experience. There were enough staff deployed to meet people’s needs.

Staff had not completed all required training, including training to support people with individual health conditions which meant they did not always have the skills and knowledge needed to safely meet people’s specific needs. Furthermore, only 5 out of 18 staff had completed training in relation to Mental capacity assessment and Deprivation Liberty Safeguards (DoLS). The provider had not been working in line with nationally recognised training recommendations, and systems to ensure training was delivered and monitored were not effective. The registered manager told us that further training had been booked, including training on people’s specific health needs and mandatory courses, which would be completed by April 2026.

Processes for monitoring training required improvement. Training records were not consistently maintained, meaning it was unclear when staff had last completed courses, when refresher training was due, or how frequently training should be delivered. This meant we couldn't always determine if staff had been suitably trained to meet the needs of the people they supported. We were assured people were safely supported.

Staff were supported to have one-to-one supervision sessions, appraisals and team meetings.

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.

Staff demonstrated a good understanding of required infection‑control practices during an outbreak. The provider had an infection prevention and control (IPC) policy that reflected current good‑practice standards. The home was visibly clean, tidy and fresh. Personal protective equipment (PPE), including gloves and aprons, was readily available, and staff were observed using it appropriately. This meant the risk of infection to people at the home was reduced.

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.

One person’s medication was prescribed as one tablet four times a day, but the medication administration record (MAR) had been handwritten to show a three‑times‑daily dose. A health professional had reduced the dose on 23 December 2024, yet this update was not communicated to staff, and the MAR continued to be handwritten with a different dose from December 2024 to the time of inspection. The discrepancy was not identified or escalated, meaning the prescription was not accurately reflected in the person’s medication records. This meant the person was at risk of receiving medication that did not align with the prescriber’s instructions.

Topical medicines, such as creams and ointments, were being applied without the use of topical medicine administration records (TMARs) or body maps. We reviewed MAR charts we found gaps where prescribed creams had not been recorded as applied. This is important so staff know where to apply the medicine on the body and they are applied to the frequency as prescribed.

Medicines prescribed to be taken ‘when required’ (PRN) did not have protocols in place. One person was supported with a prescribed cream to support their skin as they were prone to blisters, there was no guidance for staff when and how medicine should be applied. There was a risk staff were not administering PRN medicines consistently or in line with the person’s assessed needs.

This meant people were at risk of receiving topical and PRN medicines in a way that was inconsistent, unclear, and not aligned with prescriber instructions.

Records showed staff had completed training in safe administration and management of medicines.

People told us they felt their medicines were managed safely. One person said, “I get my meds at the right times on the right days, I no longer have to worry about them.”