Withins (Breightmet) 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 this assessment we reviewed 5 quality statements from this key question. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained. 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 service was in breach of legal regulation in relation to the ways people’s medicines were managed safely at the service.

This service scored 59 (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.

The provider used 3 files to store accident and incident information. An accident file, an incident file and a safeguarding accident / incident file, in which any documentation linked to safeguarding alerts reported to the local authority had been stored. No overarching log or index system was used. As such, it was not clear in which file specific documentation was stored, nor was it evident how the provider was able to identify patterns or trends, such as how often a person had fallen and whether this was at specific times of day.

Accident and incident forms explained what had happened, actions taken and some outcomes. However, no follow up actions had been documented on the forms we looked at. For example, where care plan and risk assessments had been reviewed and updated, or where people had banged their head following a fall or other incident, post-accident monitoring had not been completed for 24 to 48 hours, to check for signs of concussion, confusion or complications not first apparent at the time of the accident or incident. We also found limited evidence lessons learned had been considered, to help minimise the risk of a reoccurrence. Each incident or accident had been reviewed by management. However, from examples seen, this focussed on reviewing what had happened and actions taken, as well as checking CCTV for further information if the incident was unwitnessed. It was not clear what learning had been learned from accidents and incidents and how this had been shared with the wider staff team.

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 worked closely with commissioners and other stakeholders, such as social workers, to ensure people’s transitions into and out of the service were successful. A hospital passport was used to help ensure continuity of care for people temporarily transitioning out of the service, for example being admitted to hospital. This document covered people’s needs, likes, dislikes, and medical conditions, along with any medication they took. Sections of the document were completed on the day of admission to hospital, or elsewhere to ensure the most up-to-date information was sent with the person.

A social worker told us how for a recent placement, there was a risk of it breaking down. However, the management worked with the partner to manage the risk and implemented plans which ensured the person felt safe, gained the level of intervention needed and ultimately remained at the service.

People and relatives told us how the provider supported them when they first moved into the home. One person said, “They made it easy for me to settle in, if I had any problems the staff would deal with them.” Furthermore, people and family members told us the provider effectively shared their information when they went to hospital. A relative said, “When [they] went into hospital, a carer went with [them], and they made sure the staff had all his information.”

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.

The provider did not consistently ensure risks to people were identified, assessed, and recorded. Documentation reviewed by the district nurse stated a person had a catheter in situ which they regularly removed themselves; however, there was no associated risk assessment or guidance within the care plan to direct staff on how to manage this risk. It was identified that 2 people had experienced seizures, but these risks were not reflected within their risk assessments or care plans. As a result, staff were not provided with clear information on how to safely support people when risks were present. Risk assessments not being in place was also a concern at the previous inspection.

Risk assessments were largely generic in nature. Most risks and control measures were the same across people’s care records, with the only difference being their name had been inserted. This indicated the risk assessment process was not always person-centred and individualised. Care plans lacked detail around how staff would deliver care in relation to risks. This was also identified as a concern at the previous inspection.

People’s risk assessments and care plans were not always effectively implemented, monitored or recorded by staff. People’s weight, their risk of malnutrition and their bowel movements were not being monitored or recorded consistently.

We did note some positive examples of specific risk assessment. One person who required the daily application of emollient creams had a risk assessment linked to the flammable nature of such creams, with actions for staff to be mindful of such as changing bedding and clothes daily.

Staff supported people who communicated their needs, emotions or distress. Staff managed this in a positive way which protected their rights and dignity and maximised learning for the future about the causes of the distress.

The provider did not always make sure staff were up to date with mandatory training. However, there were enough qualified, skilled and experienced staff, staff received supervision and development opportunities.

The registered manager told us all training was completed in person and face to face. Staff were complimentary about the training completed. However, staff did not always receive training appropriate and relevant to their role, and some staff had not completed essential training in a timely manner. Although staff had completed a foundation level training for autism and learning disabilities, the provider was unable to evidence advanced training. This was a requirement of the service, as they were registered to support people with a learning disability and autistic people, so should have been ready to commence with such support at any stage. It was also confirmed the provider had supported autistic people and people with a learning disability in the past.

The care managers did not have the appropriate medication training to be completing competency assessments for senior members of staff. This was raised to the registered manager who has enrolled the leaders onto a relevant training course.

The provider ensured there were appropriate staffing levels and skill mix to make sure people received consistently safe, good quality care that met their needs. Staff told us the staffing levels were sufficient. People were pleased with the staffing levels also, a relative said “Yes there is [enough staff], that’s one of the things which attracted me as they have a floating member of staff in case someone needs to be accompanied to the hospital.”

The provider ensured there were robust and safe recruitment practices which made sure all staff, including agency staff and volunteers, were suitably experienced, competent and able to carry out their role.

The provider was adhering to their staff support policy and procedures through completion of appraisals and supervisions. Monthly supervisions were ‘group’ based meetings which focussed on a specific area of care, such as dignity, safeguarding, food hygiene or infection control, rather than being individual meetings with staff to discuss their role, any issues and areas for improvement. However, staff stated they were happy with support provided and happy to discuss any issues with management if required.

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

Staff had completed training related to medicines, but not all staff had their competency assessed.

Medicines were stored securely. We found that staff monitored the temperature of rooms and fridges used to store medicines, however they did not always document if they had taken any action when it was outside of the recommended range.

We saw no evidence of gaps on MAR (medication administration records), and balances of medicines reflected stocks of medicines held, however we found that TMAR’s (topical medication records) used to record the application of creams were not always completed in a way that assured us that creams were applied as directed.

Although instructions for medicines that were given when required (PRN) were available they did not always contain person-centred information. Staff did not always document the outcome for people when these medicines had been given, so, it was not clear if they had been effective or not.

The time a medicine was administered was not always documented for time sensitive medicines. For example, we could not be assured that the prescribed interval for some medicines had been observed, or that a medication prescribed to be given at a specific time had been administered safely; this left people at risk of receiving medicines at the incorrect time.

People were supported to take social leave or look after their own medicines. However, this was not reflected in peoples care plans and risk assessments had not been completed to ensure it was safe to do so.

We found for people who needed their medicines administered covertly (hidden in food and drink) there were instructions available for staff to follow, however, where instructions from an appropriate healthcare professional were available, staff did not always follow these. This could lead to people receiving their medicines in an unsafe way.

The use of powder to thicken drinks for people at risk of choking was not always documented accurately so we could not be assured people had their drinks thickened in the prescribed way.