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 inadequate. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was previously in breach of legal regulations in relation to safe care and treatment, safeguarding and safety of the premises. Whilst we found improvements had been made, further work was required, and the provider remained in breach of these regulations.
 

This service scored 53 (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 could not demonstrate they always have a proactive and positive culture of safety.

The provider’s policy required staff to complete incident forms, in the event of people sustaining an injury. Staff told us they knew how to complete incident forms on the provider’s electronic care planning system and completed them, but records reviewed did not demonstrate the required incident forms were always completed. We saw some injuries people sustained were only recorded within the staff’s handover book. Although staff photographed injuries people experienced, there was not always a body map to show the site of the injury, in case the injury had to be escalated under safeguarding procedures.

The lack of some incident forms meant it was not clear, who had been informed of the injury and what oversight had taken place to ensure any required actions were completed. Although professionals told us the registered manager alerted them if a person needed any care following an injury and staff said any learning from incidents was shared. There was a lack of documentary evidence to always demonstrate the actions taken.

However, following the site visit, the provider supplied evidence they have acted on our feedback and issued staff with updated guidance on their requirements in relation to the completion of incident records and body maps. They have detailed how this requirement is to be checked both daily and weekly. It will take further time for them to embed this and to be able to demonstrate its effectiveness.
 

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.

The provider had a written policy to guide and inform staff about the requirements when people were admitted to the service. People’s pre-assessments were completed before people moved in and shared with staff, to inform them of people’s needs.

Staff were then updated if people transferred in or out of the service at staff’s shift handover meeting. Processes were in place to ensure people's required records were sent with them if admitted to hospital.
 

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

We found whilst DoLS applications had been made for people who had restrictions in place and relatives confirmed they had been consulted about decisions. The provider was not confident with the recording of MCA assessments and best interest decisions on their electronic care planning system. Only 1 person subject to restrictions had documented MCA assessments and best interest decisions on the system. Whilst staff were aware of restrictions in place for people, there was a lack of records to demonstrate what restrictions were in place and why they were in people’s best interests. During the inspection the provider supplied evidence they have acted on our feedback and have started the process of completing the required documentation. It will take further time for them to embed this and to be able to demonstrate its effectiveness.

However, the provider had a process to track and monitor people's DoLS status. CQC has been informed when DoLS applications have been approved, as legally required.

Records showed all staff apart from 2 had completed the provider’s safeguarding training and they all had access to relevant guidance. Staff understood the types of abuse and how to safeguard people. Professionals and relatives spoken with felt people were kept safe.
 

The provider did not demonstrate they always managed risk to people well.

The provider advised 1 person required staff to re-position them regularly to manage the risk of them developing pressure ulcers. There was a lack of written guidance within their care plan to instruct staff regards how often to re-position them and their re-positioning records were incomplete. Although we were assured from speaking with staff the person had been re-positioned and had not suffered harm, their records did not demonstrate the care provided. There was evidence the correct setting for people’s air mattresses was recorded and checked daily and professionals confirmed they had no concerns about people’s skin integrity.

People had a range of risk assessments in place which identified risks to them and the measures in place to mitigate them, including any equipment required. The provider told us and records confirmed they were not up to date with all the monthly reviews of people’s risk assessments as required by their electronic are planning system. However, they were aware of this issue and planned to streamline the number of people’s risk assessments, so only those relevant were completed.

Staff had completed moving and handling training and provided a person with reassurance as they transferred them safely. There were relevant policies in place in relation to falls, choking, epilepsy and diabetes to guide and inform staff, who had also completed training in these areas.
 

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

The provider, following the last inspection had commissioned the required works to the fire doors and compartmentation gaps, which could allow fire to spread. These works had only recently started, due to issues beyond the provider’s control. We spoke with the provider and during our inspection, they provided evidence of a schedule and timeline for the completion of these essential works.

There was evidence required fire safety checks were completed and documented, however, we noted some gaps in the records. There was a lack of records to show the acoustic door closer checks, which are required to show fire doors close and seal correctly, had been completed. Staff completed fire training which included a fire drill, there was a lack of written evidence 4 staff had completed this training. However, people had personal emergency evacuation plans in the event of a fire.

The provider was not aware of the need to ensure water temperature checks were completed at the taps nearest and furthest from the water storage tank. Whilst water temperatures were taken to check any scalding risk, they were not taken at the correct point to ensure the temperature was correct to prevent legionella growth. Legionella can cause a serious type of pneumonia called legionnaires' disease. The provider advised they would be obtaining a water temperature probe to enable these checks to be completed. There was a legionella risk assessment and annual legionella sampling took place.

The provider was not aware of the need to establish if there was any asbestos in the building. Since our site visit, the provider confirmed they had booked an asbestos survey.

The provider had ensured required gas; electrical and equipment safety checks were completed. The external gate to the premises was now secure for people’s safety. There was relevant training and guidance for staff and the provider had attended a health and safety course for managers.
 

The provider could not demonstrate staff all received effective support and supervision.

Staff said they received supervision, but limited supervision records were provided and the provider did not keep an overall record of when staff supervisions had taken place or were due. They could not demonstrate staff supervisions took place in accordance with the 3 monthly requirement of their supervision policy. We did not identify this impacted people’s care.

Staff recruitment records were not readily accessible on-site. However, they were provided afterwards and showed the provider had safe recruitment practices.

Staff completed a broad range of on-line training for their role, including appropriate training for people with a learning disability and autistic people. However, as staff completed their training on different training platforms depending on their role and training needs, it was not clear what training some staff had completed. The provider had administrative support and they were assisting them to provide a full overview of staff training across all platforms, as the current process was ineffective.

The provider reviewed their staffing requirements weekly to ensure sufficient staff with the correct skills were deployed. Whilst the core staff was stable and well-established the provider also used 2 agencies who provided staff who were familiar with people’s needs if required. We observed there were sufficient numbers of staff to support people. Staff responded promptly if people required support.

 

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 had completed infection control training and all but 1 had completed Control of Substances Hazardous to Health (COSHH) training. The provider had an infection control policy to guide staff and an infection control champion had recently been appointed, ready to lead and guide colleagues.

Staff were seen to use the personal protective equipment provided (PPE). We saw the home was visibly clean and there were no malodours. Schedules showed cleaning was recorded as having taken place most but not all days. For example, there were some gaps on days at the weekend when housekeeping staff had not worked. The home was well ventilated.

The provider had a recent food hygiene rating of 5 which is very good. The home’s 2 cats were now fed in the hallway, as opposed to people’s bedrooms. There was not a risk assessment for the cats, however, the provider completed this as soon as we brought it to their attention.

Staff supported people to attend to their personal care needs. We saw people were well presented.
 

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.

Medicines were stored securely and people received their regular medicines as prescribed. However, the provider did not always ensure that processes in place to manage medicines were safe and met people’s individual needs and preferences.

Some people were prescribed ‘as required’ medicines. However, protocols were not always in place to guide staff on when these medicines should be administered. For example, 1 person had Paracetamol prescribed to manage pain when required, but there was no information describing how the person displayed symptoms of pain and whether they were able to inform staff they were in pain. In addition, there was a lack of written information to support staff in administering medicines with a variable dose. This meant people may not always receive these medicines consistently or at the time they were required.

Risk assessments for people prescribed high risk medicines lacked sufficient detail. For example, we saw risk assessments in place for people prescribed anticoagulants that did not include details of potential risk of falls or bleeding and the monitoring requirements. This meant staff did not always have the information required to identify, monitor or respond to potential medicines-related risks, placing people taking these medicines at risk.

Records of medicines refrigerator temperatures did not include the minimum and maximum temperatures over a 24-hour period, as required by the service’s medicines policy. Therefore, the provider could not be assured medicines requiring refrigeration were stored at temperatures in line with manufacturers’ guidance. Although, at the time of inspection there were no residents being prescribed medicines that required refrigerating.

Staff carried out regular medicines audits and acted when needed. However, these audits had not picked up the areas of improvement that were identified during the inspection.