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 inadequate. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff listened to concerns about safety and investigated and reported safety events. The provider had put systems in place to review incidents and accidents and monitor for trends. There was a governance tracker in place to monitor events for themes and identify actions needed to be taken. When people had an accident such as a fall, staff completed documentation and took the appropriate steps to safeguard people. There were systems in place to monitor and record people’s health and wellbeing in case symptoms escalated. Staff discussed learning in handovers and meetings and shared information through communication systems attached to the care documentation.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. The registered manager had at times been over reliant on referral documentation received rather than completing their own independent assessment before people came to stay at the service. The registered manager had taken on board that they needed to do their own independent assessment before people came to the service and had implemented this process to ensure continuity of care moving forward.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. People told us they felt safe living at the service. One person said, “I do feel safe, I am well looked after and if I was worried, I can talk to the manager.” Another person said, “Nothing worries me here.”

Staff had received training in safeguarding, and any safeguarding concerns alerted to staff were raised with the registered manager and discussed with staff to keep people safe. Staff told us they knew how to raise safeguarding’s and would escalate concerns if they had any.

The registered manager shared concerns promptly and appropriately and worked with the local authority to investigate these. People were supported to discuss concerns with social workers and where needed had advocates to help them discuss any concerns. The registered manager took on board safeguarding investigation feedback and implemented changes where needed to keep people safe.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks were identified for people and guidance was in place to mitigate risks and guide staff on how to give safe care. Medical conditions were identified, and clear documentation was in place to provide safe support to people. Where people needed specific equipment to support their needs, we saw this was in place. Risks to people’s health and wellbeing were discussed with them to promote the best outcome. Staff respected people’s decisions whilst supporting them to live as safely as possible.

Personal emergency evacuation plans (PEEPS) contained all the information staff, and the fire service may need to evacuate people safely in the event of a fire.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. We found the registered manager and provider had made improvements at the service since the last inspection. An additional maintenance person had been employed to help make improvements and attend to general maintenance issues more promptly. There was a continued refurbishment plan in place to continue making improvements. We noted repairs had been made around the service where needed. Rooms had appropriate coverings over windows to ensure privacy and prevent light pollution from early sunrises in the summer and streetlights.

Communal areas had been redecorated and new comfortable furniture provided. There was space for people to meet and socialise comfortably with a dedicated lounge, activity room and dining area. Signage had been added to help people navigate their way around the service.

People’s bedrooms had been provided with new furniture where needed and redecoration of rooms was on-going. One person told us, “Staff are going to decorate my room, I am going to have soft pink on that wall and white on the others.”

The service was no longer cluttered with equipment stored appropriately in dedicated areas.

One member of staff told us, “We have sorted out a lot of things and got of rid of what we do not need. We have made better use of the storage space we have.” A maintenance member of staff told us, “The provider has let me get on making repairs and has allowed me to buy all the supplies and use quality products without question.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The registered manager recruited staff safely. Applicants provided a full working history, references and undertook a disclosure and disbarring check (DBS), to ensure they were suitable to work with vulnerable people. New staff underwent a full induction including working with more experienced staff whilst they got to know people and their routines. One member of staff said, “My induction was good, I completed online training whilst waiting to start work. When I started, I completed manual handling and medicine training.”

The registered manager told us they had actively recruited new staff. Staff competency was monitored and appropriate disciplinary action taken if standards were not met. The registered manager had a system in place to monitor people’s dependency against staffing needs. However, we still received mixed feedback on staffing with some staff feeling they needed an additional staff member in the morning. We discussed this with the registered manager who informed us they had been reviewing staffing levels with the intention of adding another staff member.

People told us, “The staff usually put the buzzer by me, I do use it, staff come into the room, and we have a chat and a laugh and joke, that is what makes me like it here.” Another person said, “If I use my buzzer they come in a few minutes.”

Staff had been provided with additional training to enhance their skills. This included face to face safeguarding, moving and handling and dementia training.

There was now a supervision structure in place with staff being provided with supervision every 3 months and regular staff meetings scheduled. The provider had sourced additional supervision for the registered manager to give them an opportunity to develop their skills and provided them with mentoring.

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 received training in infection prevention control (IPC). The registered manager had put systems in place to monitor the environment and had employed new dedicated cleaning staff. The deputy manager had taken a lead on overseeing cleaning and housekeeping at the service. We noted the environment was clean, free from dust and odours. Equipment was now stored appropriately and cleaned effectively.

Staff had access to personal protection equipment (PPE) when needed, which was now stored appropriately.

The provider made sure that medicines and treatments were safe and met people’s needs. Staff had received training in medicine management and had their competency to support people with medicines checked. Medicines were stored safely and securely. We did a random check of medicines and found creams and eyedrops had been dated when opened and were stored appropriately. Protocols were in place for as and when required medicines (PRN).

Regular audits were in place and where discrepancies were noted these were investigated by the registered manager or deputy manager to identify the cause and any actions needed. We noted some discrepancies with medicine stock counts had been identified on the audit which were being investigated.