Wymeswold Manor

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.

This is the first assessment for this newly registered service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment, safe environments and safe and effective staffing.

This service scored 31 (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 provider did not learn lessons from incident and accidents nor put measures in place to reduce the likelihood of these reoccurring. Accidents and incidents had not always been reviewed and dealt with by the management team in a timely manner. For example,the provider had identified 1 person was at risk of leaving the service without staff knowledge which they were unsafe to do. Despite this known risk, the person was able to leave the service unaccompanied, and staff were not aware they were missing until after the event. The provider failed to undertake a thorough investigation to establish how the incident occurred and did not demonstrate appropriate action had been taken to reduce the risk of recurrence. In addition, the person's risk assessment was not reviewed or updated following the incident to reflect the changed circumstances, identify any lessons learned, or ensure staff had clear guidance on managing the identified risk. This meant opportunities to learn from the incident and improve safety were missed.

The provider did not always ensure people experienced safe and effective transitions into the service.

People's needs were not comprehensively assessed when they moved into the service to ensure staff had the information required to provide safe, person-centred care. For example, 2 people had recently been admitted to the service; however, the information available to staff consisted of a brief two-page summary of their health, care and support needs. This did not provide sufficient detail about their individual needs, risks, preferences or the support required to achieve positive outcomes. The provider had not ensured complete assessments and care plans were developed promptly following admission. This meant there was a risk staff did not have the information they needed to understand and respond to people's needs consistently and safely during the transition into the service.

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

People told us they felt safe living at the service and were confident staff would support them when needed. However, we were not assured potential abuse had been identified or appropriately managed.

We identified concerns in relation to incident recording and safeguarding escalation. An incident was recorded in a person’s daily notes where they were described as having ‘lashed out’ at another person. This incident was not fully recorded, and the documentation did not provide sufficient detail to understand the full circumstances, including the background to the incident, staff response, or outcomes. In addition, no incident form had been completed. As a result, the event had not been appropriately captured within the provider’s incident reporting systems. We could not be assured appropriate safeguarding considerations had been undertaken, including whether the incident met the threshold for referral to the local authority safeguarding team. Therefore, the provider failed to ensure they had systems in place to prevent further harm or abuse.

Training records showed not all staff had received safeguarding training. However, staff we spoke with were able to clearly describe signs of potential abuse and the actions they would take if concerns were identified.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this is done through the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005. The provider had made DoLS applications where necessary; however, staff did not always have easy access to key information relating to people’s DoLS authorisations, including any conditions or guidance. For example, one person’s care records contained contradictory information regarding whether a DoLS application had been made, which created potential risk of confusion in the application of restrictions and safeguards.

The provider did not work well with people to understand and manage risks. Staff did not 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 related risk assessments were not all person-centred or reflective of people’s individual needs. Some care plans contained little guidance for staff to follow to provide consistent care delivery to ensure peoples’ health and safety. Where care plans were in place staff did not always follow guidance contained within them. For example, 1 person who was at risk of developing pressure damage required daily skin checks to monitor their skin integrity. However, there were no records to demonstrate these checks had been completed. This meant the provider could not be assured that changes in the person's skin condition would be identified promptly and appropriate action taken to reduce the risk of pressure injury.

People’s Emergency Evacuation Plans (PEEP) are a record that instructs staff about support people would need to evacuate in the event of a fire or emergency. These did not always contain clear, safe and practical guidance for staff to follow in the event of an emergency. For example, 1 person's PEEP instructed staff to contact the person's next of kin if they refused to evacuate. This guidance was inappropriate as seeking consent from a relative during an emergency could cause a delay in evacuation and place the person and others at increased risk.

Whilst staff we spoke with had an understanding of people’s care and support needs, care plans for people who lived with specific care and support needs were not all accurate. This had the potential to impact on safe care delivery.

The provider had not consistently ensured that the environment was safe, well-maintained, and appropriately managed to mitigate risks to people.

We found wardrobes in people’s bedrooms had not been secured to walls to reduce the risk of injury from heavy furniture toppling. The provider had not identified, or risk assessed this potential hazard. This meant there was no documented assurance that the risk of harm from unstable furniture had been assessed, monitored, or mitigated.

In addition, we observed broken moving and handling equipment that had been out of use for over a year stored in a communal bathroom. This posed a risk of inappropriate use and demonstrated a lack of effective systems for the management, removal, or disposal of unsafe equipment.

Further concerns were identified in relation to the safe storage and control of hazardous substances. The laundry room door did not have sufficient locking mechanisms and was observed to be open during the inspection, with chemicals hazardous to health (COSHH) stored inside and accessible. In addition, COSHH products were found in the communal kitchenette area, which were also accessible to people using the service. Following inspector intervention, the provider installed a lock to the laundry room door and removed the COSHH products from the communal kitchenette.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The provider did not operate effective and safe recruitment practices to ensure they employed suitable staff, in line with relevant legislation and their own policy. Guidance states providers must keep specific information on staff, including employment history and conduct evidence. Some staff employment histories contained gaps which were not explored by the provider, and their place of prior employment references were obtained after the staff member had commenced employment. We also found some staff did not have evidence of identity checks within their recruitment files. This meant the provider could not be assured that staff were suitable to work with vulnerable people. However, the provider had undertaken Disclosure and Barring Service (DBS) checks. The DBS helps employers make safer recruitment decisions and prevent unsuitable people from working with people.

The provider had not ensured staff received the training, assessment and support necessary to carry out their roles safely and effectively. Training records showed that not all staff had completed safeguarding training, moving and handling competency assessments, or equality and diversity training. Staff had also not completed learning disability training in line with the requirements of the Health and Care Act 2022 which is a legal requirement for CQC-registered providers. This placed people at risk of receiving support from staff who may not have had the necessary knowledge, skills and experience to meet all their needs safely and consistently.

There were not always staff deployed to meet people’s needs safely. The impact of this has been reported in caring.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Areas of the service were in a state of disrepair. For example, handrails, door and window frames had chipped paintwork exposing porous wood. This meant areas around the home could not be thoroughly cleaned or sanitised. We also found used personal protective equipment (PPE) had been left in the sluice sink as there was no appropriate waste bin available for disposal. This left people at risk of cross infection.

We identified multiple mattresses and pressure cushions were soiled and foul smelling. People’s bedding was also observed to be stained. A relative told us, “I’ve changed bedclothes 2 or 3 times, because they weren’t clean.”

People were not protected from water borne infections. We found a build-up of limescale on multiple taps around the service. Limescale deposits can be a breeding ground for dangerous bacteria including Legionella bacteria which causes Legionnaires' disease. Records referenced shower-head descaling but did not record any descaling of tap outlets.

Most of these issues had been identified during the Local Authority’s infection control inspection earlier in the year but had not been rectified by the provider.

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

People did not always receive their medicines safely or as prescribed.Records showed 2 people had received an overdose of their prescribed medicines on multiple occasions and 1 person had received an underdose. These medicine errors had not been identified by staff or the provider at the time they occurred, and appropriate medical advice had not been sought.

When required (PRN) medicines were not always managed safely. Not all people had PRN protocols in place. Where protocols existed, some did not guide staff on when to administer medicines that had variable doses or when prescribed 2 different pain killers. Where people were supported with PRN medicines, staff did not consistently record the reason or outcome of administration. This meant the effectiveness of the medicine could not always be reviewed.

Where medicines were due to be returned to the pharmacy or on to a person’s new accommodation, they were observed to be on the floor in the medicines room. This is not in line with national guidelines which stipulate they should be stored securely in tamper-proof containers until they are collected.