Wall Hill 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 requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service continued to be in breach of a legal regulation in relation to people’s safe care and treatment.
 

This service scored 38 (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 based on openness and honesty. They did not act or investigate concerns robustly and lessons learnt from incidents were not always identified in order to embed good practice.

During the last inspection [25 July 2024 ], the provider was in breach of 4 regulations, and we served 2 warning notices. The provider was due to be compliant with the regulations by 01 November 2024. During this inspection, we followed up on these warning notices to check whether the provider was compliant with the regulations. The provider had not met either of the warning notices and remained in breach of the regulations. Warning notices are served when providers have failed to comply with the relevant legal requirements, where the quality of the care they are responsible for falls below the standard required.

We received mixed feedback from people regarding feeling safe living in the home. One person told us, “I'm happy living here, I feel safe.” However, another person told us, “No, I don’t feel safe living here, not at all.” Relatives told us they felt their family member’s received safe care and treatment.
However, we observed numerous incidents involving people living in the home shouting and threatening other people. These incidents were not always challenged by staff and on 2 occasions we needed to ask staff to intervene on people’s behalf to keep people safe. Staff told us negative interactions between certain people living in the home occurred often throughout the week. We raised a safeguarding referral with the local authority on behalf of 2 people who were targeted by 1 person living in the home. Incidents involving people shouting and threatening others were not always recorded as incidents, therefore they were not always investigated.

We reviewed incidents which were recorded by staff, these contained limited detail and follow on actions or lessons learnt were not always recorded. This put people at risk of harm. The manager explained they would be completing additional incident recording training with staff.

The provider did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

People living in the home were not always suited with the support the provider could provide, and the provider was not registered to accept people with these support needs, this included people with learning disabilities and autistic people and people with substance dependency issues.

One person told us they should not be living in the home and felt the home did not meet their needs. They said, “I feel frustrated living here. Staff are okay but I shouldn’t be here.”

Staff told us some people should not be living in the home due to their support needs; this was in reference to people with a learning disability and autistic people. One staff member said, “No, I don’t think it’s the right place for them to live.”

People living in the home were not monitored safely, we observed 1 person sitting in the same seat throughout the day. This person was unable to reposition themselves without the assistance of a hoist. When we checked records to confirm whether the person had been repositioned, we found they had not. We checked previous days and found prolonged periods of times when the person had not been supported to reposition. This put the person at risk of harm due to skin integrity and infection risk. We raised a safeguarding with the local authority on behalf of this person. In response to our feedback, the manager sent an email to staff and spoke with staff about the importance of repositioning people regularly.
Where care plans recorded people required support with their oral care, staff were not consistently recording whether people had received support within daily records. This meant the provider could not be assured staff were consistently meeting people’s oral health needs, which placed people at risk of poor oral health and associated health conditions. The provider responded by introducing new systems to monitor oral health tasks.
 

The provider did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, abuse and avoidable harm and neglect.
During this inspection, we made 11 safeguarding referrals on behalf of people living in the home as we were not assured these people were being supported appropriately. This included, 2 people we observed being targeted by another person living in the home; 1 person who experienced isolation without a best interest decision being in place; 1 person who was supported by staff using poor moving and handling techniques, 1 person who was distressed but did not receive an appropriate response from staff; 1 person who made comments suggesting they were experiencing low mood and needed a referral to a health professional; 1 person who had their diet altered without a clear assessment in place; 2 people who were alleged to have received poor treatment from a staff member, 1 person who was allegedly assaulted when we reviewed incident records and 1 person who told us their choices were not always respected. The local safeguarding authority told us they were waiting on the provider to share additional information for 1 of these concerns. The other concerns were either closed as they did not need further investigation or were found to be unsubstantiated.

The provider carried out an investigation into each safeguarding concern, however the investigations were brief, and we raised concerns about the quality of their investigations.

We received mixed feedback from staff regarding whether they felt their concerns would be taken forward. One staff member told us they had raised a concern around poor practice, but they felt action was not taken forward. We asked for the investigation into this concern; however, this was not available during the site visits. The registered manager later shared their investigation with us, they had recorded they would obtain a written record from a staff member in February 2025. However, the statement was not obtained until April 2025, there was no record of this being followed up during this period.

During the last inspection, we served 2 warning notices. Part of these concerns consisted of relatives being identified as decision makers for people without legal authorisation. This concern continued to be found during this inspection, where relatives were identified in care plans as decision makers for the person.

Relatives told us people were safe living in the home. One relative said, “I would say [my relative] is safe here. They had a fall a few months ago, the staff let me know straight away.”
Staff told us they received safeguarding training, and they told us about the types of abuse including the signs and symptoms.
 

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. Care plans and risk assessments were not always kept updated with people’s changing needs and abilities. Where 1 person was risk assessed as being at high risk from self-harming behaviour, their care plan made no reference to these behaviours. The risk assessment did not detail any strategies for staff to use in the event the person started to self-harm. This meant the provider failed to equip staff with the knowledge and skills required to keep the person safe. One person displayed distressed behaviours throughout both site visits, where they targeted and threatened others, staff did not always respond appropriately. For example, staff supported one person to sit next to another who was threatening them. We needed to intervene by suggesting staff consider asking the person being threatened if they wanted to move seats, which they agreed, and the person was supported by staff into another lounge. Whilst 82% of staff had completed behaviours that challenge training, the staff failed to act and intervene to protect the person from emotional harm and duress. We reviewed the risk assessment for the person displaying distressed behaviours towards others. There was no risk assessment in place to address these behaviours. This placed people at risk of harm because staff were not provided with effective strategies to intervene and support people when they became distressed. The provider responded to our feedback by completing a risk assessment.
We observed people being hoisted safely. However, we also observed a person receiving poor moving and handling support when they were being supported to sit in a chair. We raised a safeguarding concern with the local authority on behalf of this person and the provider carried out an investigation.
Within the previous warning notices, we raised concerns over the inconsistency of care plans for people with specific health conditions. We continued to find these concerns. The care plans in place for some people with specific health conditions did not always detail the signs and symptoms of these health conditions for staff to monitor and how to respond appropriately. Staff were able to describe to us the signs and symptoms of the health conditions. However, there was a risk new staff or agency staff may not be aware of signs to be aware of, which placed people with specific health conditions at risk. The provider responded to our feedback by updating the identified care plans.
 

The provider did not always detect and control potential risks in the care environment. Relatives told us they had observed the provider carrying out health and safety checks, such as fire alarm checks. Staff told us about moving and handling equipment and how often equipment needed to be serviced.

Our observations found people did not always have access to tables to place their drinks upon. We observed 1 person sitting with a warm drink, they attempted to put their warm drink on the floor, they appeared very unsteady and were unable to achieve their task. They then attempted to stand holding their warm drink. We needed to intervene and remove the drink because there were no staff present. This placed the person and others at increased risk of scalds and falls due to environmental design. The provider responded to our feedback by purchasing new tables.

Records we reviewed showed the provider carried out health and safety checks. However, water temperature checks had not been carried out for the last 2 months. This is important to prevent against potential scalds and burns. The provider responded by introducing a new system to monitor water temperatures.

We reviewed an overview of people’s Personal Emergency Evacuation Plans [PEEP]. This consisted of a list of bedrooms and associated person using the bedroom. This list meant staff could quickly check to identify which person lived in each bedroom in the event of an emergency, such as fire. However, the list was incorrect and required updating. We checked people’s individual PEEPs, these identified what support people would need to evacuate safely in the event of an emergency such as fire. However, 1 person’s PEEP did not reflect the person’s current mobility, their needs had changed but the person’s evacuation plan had not been updated. This meant staff were not given clear instruction to evacuate the person safely in the event of a fire. In response to our feedback, the provider updated both the list and the person’s evacuation plan.
 

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

People told us there were enough staff on duty to support them safely and relatives told us people did not need to wait long before receiving support.

However, we received mixed feedback from staff. One staff member said, “There is enough staff on duty, but we use a lot of agency staff, they don’t always know people well or how we work, it’s not their fault.” Another staff member told us, “There are not enough staff, we are very busy in the morning, we really struggle with agency staff.”

Our observations found staff responded to people quickly when they requested support, although there was limited engagement with people when carrying out any meaningful activities and staff did not always intervene when people showed distressed behaviours.

Within the previous warning notices, we raised concerns over staff not being trained in learning disability and autistic awareness training and substance misuse training. During this inspection, we reviewed the staff training matrix. Whilst staff had received learning disability and autism awareness training, only 61% of staff had completed substance misuse training. On day 1 of the site visit, we asked the registered manager, the new manager and the nominated individual whether anyone had a diagnosis of a particular health condition. We were told no one had this diagnosis. However, when we reviewed care plans we discovered a person with a clear diagnosis of the health condition, although staff had not received any awareness training regarding this condition. The provider responded by arranging the training for staff and by the end of this inspection the provider confirmed 100% of staff had completed this training. When reviewing staff files, we raised a concern regarding 1 member of staff completing 8 training courses on the same day. We raised our concern over the depth and level of information within these courses due to so many being completed in 1 day.

Staff were recruited safely. Recruitment files showed all pre-employment checks had been made to ensure only staff who were suitable to work with people were employed. The provider used a dependency tool to ensure there were enough staff on duty to support people.

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

People told us they lived in a clean environment and relatives said the home was regularly cleaned. One relative said, “[My family member’s] room is nice. Staff are cleaning it all the time.”
Staff told us about the importance of cleaning. One staff member said, “Cleaning is important to keep people safe and lower the risk of infection.”

However, we observed some areas of the home were tired and required refurbishment. We raised concerns over 1 person’s bedroom where wallpaper was torn and there were scuffs and stains on the walls. People who were required to sit on a supportive cushion for their skin integrity did not always have their own cushion to sit on. Therefore, the provider could not be assured these were not being shared between people and 1 of these cushions had a malodour and required cleaning. This increased the risk of cross contamination.
 

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

Following the last inspection, we raised concerns over people’s care plans not being updated in accordance with people’s medicines, in particular ‘administer when required’ medicines. During this inspection, we found this had not improved and care plans continued not to reflect people’s current medicines.

Following the last inspection, we raised concerns over the monitoring of the medicine fridge, because the provider was not recording the minimum or maximum fridge temperature. During the first site visit of this inspection, we continued to find the same concerns. Therefore, the provider could not be assured the fridge was maintaining a safe temperature, which is important when storing medicines. The provider responded to our feedback by purchasing a new thermometer. We returned to Wall Hill Care Home 11 days later and checked the medicine fridge again. The minimum and maximum temperatures of the medicine’s fridge continued not be recorded, despite the new thermometer being in the fridge. This left people at continued risk of receiving medicines that may be less effective or unsafe if they had not been stored at the correct temperature.

Some people received time sensitive medicines, where medicines needed to be administered before they had anything to eat or drink. However, we observed time sensitive medicines being given after food. This meant the provider failed to administer service user’s medicines safely.
When we observed people receiving their medicines, we noted 2 people chewed their tablets. One of these medicines stated they were not to be chewed or crushed. The provider had not taken any action such as discussing alternative forms of medicine with the prescriber. This meant the medicines may not have worked as intended.

Some people could not communicate whether they were experiencing pain. Records we reviewed showed the provider was using 2 pain scales. A pain scale identifies signs and symptoms for staff to be aware of when recognising people’s pain. However, when we asked staff who administered medicines to tell us about these scales, they could not. This meant staff were not trained or skilled to recognise people’s pain.

People told us staff helped them to take their medicines safely. One person said, “They [staff] help me with my medicines.” Staff told us their competency was regularly checked when administering medicines and they told us the process they would follow if they made a medicine administration error. However, staff and management could not tell us about STOMP [Stopping over medication of people with a learning disability and autistic people]. This is a national programme to stop the inappropriate prescribing of psychotropic medications for people with a learning disability and autistic people. Any provider supporting people with a learning disability and autistic people should ensure staff administering medicines have a clear awareness of STOMP.