Whitehaven 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 good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to safe care and treatment, safeguarding and safe environments.

This service scored 34 (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 have a proactive and positive culture of safety. They did not demonstrate how they listened to concerns about safety or how they investigated or reported safety events. They did not demonstrate how lessons were learnt to continually identify and embed good practice.

The provider failed to operate effective systems to record, investigate and learn from incidents. People’s care plans were not always updated after incidents and staff told us they were not confident using the new IT system for recording incidents. This put people at increased of risk of coming to harm.

The provider told us how they learnt from incidents; however, records such as people’s care plans did not always support this. For example, the provider said following an incident, 1 person should not be left unsupervised at specific times. However, this information had not then been added to the person’s care plan, to guide and inform staff. This left the person at risk of further incidents.

Staff spoken with were not all confident about how, or where to record incidents on the new care planning system as they had not received sufficient training on how to use the system in order to record information accurately and in a timely manner. The provider could not demonstrate there were formal processes in place to share learning across the staff team.

However, relatives spoken with said they were informed promptly when their loved ones had an accident. Although 1 relative said they had not been told what caused their loved one to fall.

After the inspection, the provider created policies relating to falls prevention and incidents, accidents and emergencies. Evidence was also submitted of how they had informed a relative of an incident and the actions taken in response. However, these were all dated after the inspection and were therefore not in place at the time of the inspection. We could not be assured without the inspection these would have been created.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The provider failed to demonstrate there were written policies or guidance in place for staff relating to new referrals to the service. Staff therefore did not have relevant information to understand the requirements when people moved in or out of the service.

The provider was not able to demonstrate they had robust systems in place to ensure people's care was coordinated with other health and social care services. No records were provided of professionals’ weekly reviews. People were at risk from staff not being updated about any relevant changes to people’s care.

The provider failed to produce evidence upon request of records demonstrating the sharing of key information between staff. Staff spoken with told us there was no longer a written handover since the introduction of the new care planning system and said only 1 member of staff received a verbal handover from the previous shift.

The provider was not able to demonstrate they had robust systems in place to ensure people's care was coordinated with other health and social care services. No records were provided of professionals’ weekly reviews. People were at risk from staff not being updated about any relevant changes to people’s care.

However, healthcare partners provided positive feedback about their relationship with the provider. They said the provider made appropriate referrals as needed for people and contacted them if they had concerns about people.

The provider did not demonstrate how they had worked with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider failed to demonstrate they had robust systems and processes to identify and share concerns quickly and appropriately.

The provider had not ensured all people who were subject to restrictions on their movements, amounting to a deprivation of their liberty, had the appropriate legal authorisation in place. The provider told us 9 people were subject to Deprivation of Liberty Safeguards (DoLS). However, there was a lack of evidence to demonstrate 1 person’s DoLS application to authorise the restrictions had been made, and there was a lack of evidence to show an application to renew another person’s DoLS had been made.

Where the provider had submitted DoLS applications for people, written evidence was not provided to demonstrate Mental Capacity Act 2005 (MCA) assessments had been completed for restrictions, such as the use of sensor mats and locked doors, in order to demonstrate why an application under DoLS was required.

People’s care plans did not always contain information regarding if they had a DoLS in place to provide staff with guidance on how to support people appropriately with any restrictions. People were not all deprived of their liberty in accordance with legal requirements.

Not all staff had completed training in safeguarding. Staff spoken with told us they did not know how to record details of incidents, including how to record any injuries to people on to a body map, on the provider’s new electronic system. This meant not all staff may recognise safeguarding concerns or how to report and record them. However, those staff spoken with told us they were confident in identifying safeguarding concerns.

Relatives told us they felt their loved ones were safe and looked after at the service and people were observed to be happy and relaxed in the company of staff.

After the inspection the provider submitted a policy related to safeguarding. However, this was created after the inspection date and was not in place at the time of our inspection. We could not be assured without the inspection this would have been created.

The provider did not demonstrate they managed risk to people well. Staff did not have access to the information they required to meet people’s needs safely and accurately.

The provider failed to ensure staff had access to people’s full care plans and risk assessments. This meant there was insufficient guidance for staff to refer to in the management of risks related to people’s care. This was due to an ineffective transition between electronic care planning systems. The provider has since provided care plans for people which staff can access; however, these were incomplete and lacked detail. For example, 1 person’s care plan stated they had asthma, however, it did not contain guidance for staff regarding the signs and symptoms they should look out for or what action to take to support the person. This meant we could not be assured staff would know the action to take if the person had an asthma attack, to reduce the risk of avoidable harm.

People’s care plans did not always allow staff to effectively understand people’s healthcare needs. The provider used the Waterlow clinical tool to monitor the risk of people sustaining pressure injuries, however, information about how to reduce the risk was not always in people’s care plans. For example, 1 person’s care plan assessed they were at high risk of having a pressure injury, however, it did not contain information for staff about how to reduce this risk to the person. This meant the person was at increased risk of sustaining a pressure injury.

People’s care plans did not state how often they required repositioning whilst in bed, if necessary, to ensure they did not develop pressure ulcers. The provider did not produce records to demonstrate people were repositioned when required. Staff told us whilst they repositioned people, they were not able to record this on the new IT system. However, no one had any pressure injuries during our inspection.

The provider failed to operate effective systems to oversee and ensure the safety of equipment. For example, for one person, there was no written evidence regarding what the correct setting was, for their air mattress. Staff’s daily checks on the functioning of the air mattress were not recorded. The person was at risk of developing pressure ulcers as the provider could not demonstrate either the correct setting for the air mattress, or if daily safety checks on it had been completed, and any issues identified and addressed. Therefore, the lack of effective systems to oversee the safety of this equipment had put the person at increased risk of harm.

Staff had not all received training with regards to people’s specific health needs. For example, some people had seizures, however, 5 staff providing care had not completed epilepsy training and, for 3 care staff, their training had expired. If a person experienced a seizure, staff caring for them did not have the training to respond to them effectively. This placed people who had seizures at increased risk of avoidable harm.

After the inspection, the provider submitted evidence of policies related to epilepsy, diabetes and dysphagia. However, these were created after the inspection date and were not in place at the time of our inspection. We could not be assured without the inspection these would have been created.

The provider did not always detect and control potential risks in the care environment. They could not demonstrate they ensured equipment and facilities supported the delivery of safe care.

The provider could not supply written evidence upon request to demonstrate all required safety and maintenance checks had been completed in relation to fire, water and equipment for people’s safety.

The provider failed to operate effective systems to ensure safety in the event of a fire at the service. They had failed to act on all fire safety recommendations from the fire and rescue service’s inspection of the service in 2023. They had also failed to address all issues highlighted in their most recent fire assessment in 2023. Although we saw some actions had been completed, such as addressing fire risk from the catering hatch, there was a lack of written evidence to demonstrate all required actions had been completed for people’s safety. For example, we observed fire safety risks in relation to fire doors, fire exit signage and gaps in compartmentation which would enable fire to spread. The provider did not provide evidence to show all required fire safety equipment servicing had been completed, for example, in relation to the fire alarm system and emergency lighting, to ensure they were in good working order in the event of a fire.

The provider did not provide written evidence upon request to show they had a legionella policy, legionella risk assessment or records of water safety checks to protect people from the risk of legionella. Legionella can cause a serious type of pneumonia called legionnaires' disease. The lack of effective systems and processes around the management of water safety had put people at increased risk of harm from legionella.

The provider was unable to demonstrate equipment used by people, such as mobile hoists, bath hoists or stair lift had been serviced as required to ensure they were safe for people’s use. This put people at increased risk of harm from potentially faulty equipment.

The provider failed to ensure there were effective systems in place to identify and reduce risks in relation to the safety and security of the premises. The provider told us they completed daily walk around safety checks; however, they did not provide written records of these checks, or of any actions taken. The provider had not identified hazards we observed during the inspection. For example, the gate leading from the garden to the road was fitted with a keypad lock, however, this was not working, and the gate was not secured. The provider, in response to our feedback, said they were in the process of resolving this.

The provider supplied, after the inspection, evidence a new fire risk assessment was completed in July 2025.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Staff had not all received health and safety training, or their training had expired. The provider was unable to demonstrate they had a health and safety policy in place to guide and support staff. This placed service users at risk as staff did not all have up to date knowledge about health and safety and how to reduce risks to people.

The provider was not able to provide the staff induction policy or supervision and appraisal schedules to demonstrate staff received the support they needed to deliver safe care. Although staff told us they received supervision and were supported in their role.

The provider had not always kept complete records of the checks they completed for staff recruitment to ensure they were recruited safely. We have included further details of the shortfalls we found in staff recruitment processes in the well led section of this report.

People’s care plans did not all contain a dependency assessment to determine their level of support needs, and there was no evidence of a dependency tool to assess the number of staff required to support people. However, staff felt there were sufficient numbers of staff, and relatives told us there were enough staff. We observed staff responded promptly to people’s requests and when call bells rang.

After the first site visit the provider submitted a policy related to health and safety dated 22 July 2025. However, this was not in place as required at the time of inspection. We could not be assured without the inspection this would have been created.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Staff had not all completed appropriate infection prevention and control (IPC) training, which is required for all staff. For example, 3 ancillary staff and a bank care staff had not completed IPC training. The provider was not able to demonstrate 1 member of staff, who was in a cleaning role on the second day of inspection, had completed Control of Substances Hazardous to Health (COSHH) training. People were at risk from acquiring an infection as not all staff were trained.

The provider was not able to provide written evidence upon request they had undertaken infection control audits. Therefore, they could not show they had effective oversight of infection prevention and control at the service for people’s safety.

We observed gaps in the recording of cleaning schedules. The provider was not able to evidence appropriate cleaning of the premises and equipment had been completed on those days, to minimise the risk of infection. We spoke to 1 staff member who had cleaning responsibilities who was not aware of the cleaning schedule records. However, relatives told us, and we observed, the service appeared clean, and staff supported people to maintain good hand hygiene.

The provider failed to complete effective risk assessments to reduce risks related to infection control at the service. For example, there were 2 cats at the service, and we saw evidence they were being fed in 2 people's bedrooms. The provider had not completed a risk assessment to assess any potential infection risk to people.

After the first site visit the provider submitted evidence of a policy related to pets at the service, dated July 2025. However, this was not in place as required at the time of inspection. We could not be assured without the inspection this would have been created.

The provider did not make sure medicines were safe and met people’s needs, and preferences. The provider did not have safe or effective systems in place to ensure the safe management and administration of medicines.

The provider failed to provide written evidence to demonstrate all staff had completed medicines training relevant to their role or had their competency assessed. For example, 4 staff had administered or witnessed the administration of medicines, including controlled medicines, to people without having first completed the providers medicines training or having updated their knowledge or competence within the previous year.

Some people had been assessed by health professionals as requiring their medicines to be administered covertly. There was no information available for staff to follow as to which medicines needed to be administered covertly or the safest way to disguise each individual medicine. This placed people at risk of avoidable harm in the event the wrong medicine was administered, or a medicine was administered incorrectly.

Some people were prescribed ‘as required’ medicines. However, protocols were not in place to ensure staff understood when it was appropriate to administer them, and there was a lack of written information for staff to assist them to decide the most appropriate dose to administer, when a variable dose was prescribed. This meant people may not get their medicines consistently and at the time they were needed.

People’s care plans lacked sufficient information. For example, about how they wanted to take their medicines, any risks associated with specific medicines and their preferences. There was also a lack of information about people’s specific medical conditions, for example, 1 person whose care plan said they had epilepsy did not contain information about what action staff should take if the person had a seizure.

Although relatives spoken to were happy with how people were supported with their medicines, and they told us they were kept up to date with any issues or changes needed, we found people’s medicines were not always safely and effectively managed.