Westcliff Lodge 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.

At the last assessment the service was in breach of the legal regulation related to safe care and treatment. We found at this assessment the breach continued and included the unsafe management of medicines. There were additional breaches of regulations in relation to the safety of premises and good governance. This was because the provider did not have effective arrangements to manage and mitigate risks to people and reduce the risk of the spread of infection. They also did not ensure people lived in a safe and maintained environment and did not learn lessons when things went wrong.

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 based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The registered manager did not have a system in place to review trends and themes in the service and use this as a learning opportunity to improve safety at the service. Although individual accident and incident reports were completed there was nothing in place to give an overview of the themes and trends by analysing this information to see if outcomes could be improved for people. We could not be confident all safety concerns were raised appropriately and actions taken. We found where one person had sustained an injury not all the relevant documentation had been completed to allow for this event to be analysed and lessons learned to prevent future injuries.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services. We found the registered manager had not put systems in place to ensure people’s needs could be met safely when first being admitted to the service. One person we reviewed had not had a care plan put in place following their admission to the service and their preadmission assessment contained limited information. We could not be assured staff would be able to meet this person needs safely.

Initial assessments of people’s care needs lacked detail, we reviewed 2 initial assessments, and we found consideration had not been given to all the equipment people may need for safe care. For example, we found where 1 person had a medical condition that required their legs to be raised, consideration had not been given to how this could be achieved comfortably for the person. Another person did not have access to the required stand to ensure their medical equipment could be placed safely.

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. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

We found some evidence of the service working with the local authority to investigate safeguarding concerns. Following one safeguarding concern being raised they had put steps in place to mitigate this from happening again. Staff had received training in safeguarding and informed us they would raise concerns with the registered manager or deputy manager.

However, we found the registered manager had not raised safeguarding concerns promptly and had failed to identify where concerns should be raised. Where 1 person had received an injury, we found this had not been fully investigated and a safeguarding concern had not been raised with the local authority. We identified 1 person did not appear well cared for leading to signs of neglect. This meant the systems they had in place were not robust enough to protect people from the risk of abuse. Following the visits we gave feedback to the registered manager so they could address these concerns.

The provider did not work well with people to understand and manage risks to them. Staff did not provide care to meet people’s needs that was safe, supportive and that enabled people to do the things that mattered to them.

At our previous assessments we found risks to people’s safety was not being managed safely. We found concerns with how people’s healthcare risks were being managed. At this assessment we found continued concerns with the management of people’s risks. Not all risk assessments contained guidance about how to mitigate risk to people, and some assessments did not match people’s needs. For example, there was no information available to guide staff on how to support people with diabetes in the event of higher or lower than normal for the person blood glucose levels. This meant that staff may not be able to respond appropriately to changes in the person’s medical condition potentially placing them at risk.

Where a person was being supported with a catheter there was not a risk assessment in relation to the risks associated with a urinary catheter such as the risk of infection, or of it being pulled, and how the risks could be managed safely. This meant risks to the person had not been appropriately assessed and mitigated against with guidance for staff to follow.

Personal evacuation plans (PEEPS) did not contain detail on how staff should support people to leave the building in an event of an emergency such as a fire and some had conflicting information in them. This meant we could not be assured people would be evacuated safely and staff had all the information they needed to support people safely in an emergency.

The provider did not always detect and control potential risks in the care home environment and ensured this was adequately maintained so people could live safely. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

At the last assessment we had concerns about the environment although there was some evidence of these concerns being addressed at this assessment, we found other concerns. The environment was generally cluttered with equipment stored inappropriately. The ground floor bathroom and first floor shower room were used as storage rooms for hoists and other items of equipment which limited access to them and made their use riskier to people and staff.

Some areas of the premises that needed repair had not been identified and fixtures and fittings were not provided as requires to help improve people’s quality of life. For example, we found wood missing from a door frame, damage to a ceiling following a leak and the television bracket in a person’s room broken and needing fixing. We found one room did not have adequate window coverings with a blind being fitted only partially meaning bright light could still stream into the persons room.

On the first day of assessment a free-standing wardrobe had been left in one of the lounges. Heavy furniture is a known risk for being pulled over and should not be left unsecured where people some of whom maybe living with dementia have access. A hoist and mattress had also been left in this area. We observed one person using this area during our assessment. A bench by the main door had been used to store items and a television was in front of it, not only was this a hazard for people walking around it also prevented people from accessing the seat. We observed one person wishing to sit in the area.

The environment was not dementia friendly and lacked signage and points of reference to help people navigate around the home safely. In people’s rooms we found electrical extension cables trailing across floors and walls which could be a potential hazard. The main lounge in use only had 7 armchairs with 2 dining tables and 4 chairs. This meant there was no opportunity for more than 4 people to eat a meal together and there was not enough furniture provided in communal areas to meet people’s needs should they wish to socialise together

Overall, the lack of maintenance and attention to the quality and safety of the environment meant there was a potential risk of harm to people using the environment.

The provider did not always make sure there were enough qualified, skilled and experienced staff. During the assessment we observed 1 member of staff supporting a person with an unsafe moving and handling technique. This meant that there was a potential risk of injury to both the person and staff member. Staff new to care should be supported to complete the Care Certificate, this is the industry recognised training standard for new staff. We found this training had not been provided to a staff member new to care.

Staff informed us they felt they needed an extra member of staff to provide support to people. Staff said, “Some days are worse than others, we could do with another member of staff.” and “We could do with more staff in the mornings.” The registered manager planned staffing numbers dependent on the needs of people living at the service, however we were not assured dependency levels had been analysed appropriately to take into account people’s abilities and risks. People gave us mixed feedback on the length of time they waited to receive support when they had called staff to help them. One person said, “Staff are pretty quick can be 5 or 10 minutes. I am grateful to be looked after.” Another person said, “Sometimes it is a long wait or staff ignore it. The staff are really nice and helpful though.”

The Provider did not always make sure staff received effective support, supervision and development. There had not been any new staff recruited since our last assessment. The registered manager informed us they had a stable staff team and rarely had vacancies. The deputy manager was providing regular supervision to staff; however, we found no arrangements in place for the management team to receive regular supervision or support to develop their roles. Most staff had up to date training however we found practical moving and handling training had not been provided for 18 months. This meant staff training in relation to supporting people with their mobility and transfer might not have been up to date and current.

The provider did not always assess or manage the risk of the spread of infection. Personal protective equipment (PPE) was not stored correctly which meant this could become contaminated before use. We found PPE and equipment needed to support people’s care was inappropriately stored next to flushing toilets placing this at risk of contamination before use.

Cleaning of equipment including commodes and other continence aids had not been completed to decontaminate the equipment after use. We observed that some of the equipment were visibly soiled. This meant that people were at risk of infection due to poor hygiene practices. We found open denture fix gels with no lids on, razors and toothbrushes left on people’s wash basins uncovered. This could lead to contamination of the gels and toothbrushes.General cleaning of bedrooms and communal areas was not robust leaving visible signs of dust and cobwebs. Infection prevention control audits had failed to identify and address these concerns. One person told us, “I would like staff to come and clean my room.” Following the assessment the provider informed us they would be reviewing how cleaning is provided at the service.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. There had been some improvements noted with medicine practices and a random check of medicines identified stocks were correct. However, we found some topical creams had not been dated when opened. This meant we could not be assured these creams were being used within the manufacturers recommended timeframe once opened for optimal effectiveness.

We also found an out-of-date medicine still being stored with controlled drugs which should have been returned to the pharmacy or destroyed. This meant medicine audits had failed to identify this, and action had not been taken to resolve the issue. On the first day of our visits, we found the medicine storage area had been left unlocked with the medicine cupboard and trolley also open. This meant there was a risk that unauthorised people could have had access to medicines and put themselves or others at risk of harm. Similar concerns had also been highlighted at a previous assessment, and it appeared that lessons had not been learnt to protect people from the risks associated with the poor management of medicines.