Wellburn House

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 good. At this assessment the rating has changed to requires improvement.

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 the legal regulation in relation to environmental safety, infection control and medicines management.

This service scored 56 (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.

Staff did not always identify safety related issues in a timely manner therefore opportunities to learn, identify areas for improvement and embed best practice were delayed.

During our first visit to the service, we noted potential safety related issues in relation to the home environment, cleanliness, infection control and medicines management which had not been identified by the registered manager or provider.

We raised this with the registered manager who took proportionate and reasonable steps to address these concerns. This demonstrated a responsiveness and willingness to learn, and we observed improvements at our second visit.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

There were established systems and referral pathways in place. The provider was working with district nursing services to improve communications and timelier interventions.

Care plans, including pre‑admission assessments and risk assessments, were up to date and regularly reviewed.

Staff supported people moving between different services by sharing relevant information to ensure safe transition and continuity.

The provider had safeguarding procedures and systems in place.

However, they did not always work well with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

Staff did not always concentrate on improving people’s lives or protecting them from avoidable harm and neglect.

During our first visit, we observed an unsafe moving and handling procedure which may have led to harm to the person and staff member involved.

Most people told us they felt safe in the home. However, one person commented about an unpleasant experience at night which had unsettled them. A family member expressed how they were not confident their loved one was safe. Another person reported they felt “criticised” by staff on occasions which made them feel unhappy.

These incidents were reported to the registered manager who took immediate steps to ensure people were reassured and not exposed to any avoidable harm.

Records showed where concerns were reported by staff, these had been investigated by the provider and notified to relevant partners appropriately.

Deprivation of Liberty Safeguards (DoLS) information was up to date and aligned with care plan entries. We saw evidence of applications, renewals and conditions being monitored. There was no evidence of any unlawful restrictions applied to people’s rights and freedoms.

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.

Care plans which demonstrated involvement of people in assessing their care needs and associated risks. However, staff did not always deliver care in line with the assessed risks. We found some inconsistency in the recording of positional changes and overnight checks with information recorded on paper records differing to the entries on the electronic system. We could not be assured people were receiving the appropriate support in line with their assessed needs. We discussed this with the registered manager who took action to address this.

Healthcare professionals also highlighted concerns about the management of risk to people’s skin. They were not assured this was being well managed or they were being informed of skin integrity concerns in a timely manner.

A relative reported to us they did not feel as though staff had fully considered risks associated with their relative’s skin integrity and continence needs. We discussed this with registered manager and action was taken to address this.

The provider did not always detect and control potential risks in the care environment.

Premises, equipment and environmental safety checks were carried out to support safe care delivery, but these had not always been effective.

During our first visit we observed some environmental safety concerns which may have posed a risk to people. These included unsafe window restrictors increasing the risk of potential falls from height, damage to a material stair gate and unattended housekeeping trolleys containing cleaning products accessible to people. These observations were reported to the registered manager and had been addressed when we returned for our second visit.

People had personal emergency evacuation plans (PEEPs) to inform staff on safe removal from the home in the event of a fire or untoward event necessitating evacuation.

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

Recruitment checks were completed and new staff received a structured induction.

The registered manager maintained oversight of staffing levels and checked these against people’s assessed care and support needs. These were further monitored by the area manager and operations manager to ensure people’s needs were met in a safe and timely manner.

On-going training, which one staff member described as “amazing”, ensured they maintained their knowledge and skills required to deliver safe care. Staff completed training in line with required timeframes.

An effective infection prevention and control system was not fully in place.

On our first visit, areas of the home were malodorous and some furnishings were dirty. We saw wear and tear which hindered adequate disinfection and cleaning schedules were not always adhered to. Some pedal bin mechanisms were broken and lids were damaged.

Staff did not always wash their hands in between care tasks and people were not offered handwashing prior to meals. Staff did not wear any aprons during meal service and food was not always covered for tray service to people’s rooms. Environmental cleanliness shortfalls had been highlighted to the registered manager and provider at the last local authority quality monitoring visit, but sufficient action had not been taken and shortfalls remained. These observations were reported to the registered manager on day one of our visit.

On the second visit, the shortfalls observed on our first visit had been addressed. Housekeeping staff had completed a deep clean, new furnishings were in place, and staff were observed handwashing and wearing PPE appropriately.Sluice rooms and laundry facilities were suitable and waste disposal was in line with required standards.

The provider did not always ensure medicines were safely administered, stored and managed.

There was a designated clinical room where medicines were stored. However, at our first visit, there were occasions where the clinical room was open and unattended.

Each person had personalised medicines care plans to assist staff with safe administration of their medicine. However, allergies were not consistently recorded.

Staff did not always record medicine administration accurately in accordance with the prescription and there were various gaps on medicine administration records. We could not be assured people had received their medicines as prescribed. Controlled drug (CD) checks were not always recorded weekly in line with the provider’s medicine policy.

There was an inappropriate item being stored in the medicine fridge. These shortfalls had not been identified during the provider’s auditing process.

The shortfalls we found were reported to the registered manager on the first day of our visit.

When we returned for our second day, all issues identified on the first day had been addressed.

However, we observed staff had failed to keep medicines safely stored in between administration attempts. These medicines were being stored in the clinical room, in a pot on a bench next to the sink with the persons’ name written on a hand towel alongside the pot. This was not in line with safe medicines management.

This was reported to the registered manager who took action to address the issue.

All staff who administered medicines had completed medicines training and had a recorded medicine competency assessment completed.