Westgarth

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 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.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Systems were in place to record and review accidents, incidents and safeguarding events. Records detailed what had happened and actions taken. Monthly analysis considered themes and trends and demonstrated lessons learned.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had developed a structured admission pathway to promote continuity of care and positive outcomes.

For respite placements, referrals and assessment information were received from the local authority, enabling the provider to determine whether people's needs could be met safely. The manager had recently introduced pre-admission visits, allowing prospective guests and their families to meet staff and become familiar with the service. This typically included two introductory tea visits, the first attended with family and the second independently, followed by an overnight stay prior to allocation. This person-centred approach helped to build relationships, reduce anxiety, and ensure the service was able to meet individual needs effectively.

For short-stay placements, which were often arranged in response to urgent situations, the same assessment processes were followed where possible. Although pre-admission visits could not always be completed, staff gathered relevant information and, where possible, visited people prior to admission to support safe transitions and continuity of care.

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.

Staff were trained and understood how to raise safeguarding concerns. Safeguarding records were well-completed and information was shared appropriately with other agencies, such as the local authority, in a timely way. However, notifications had not always been made to CQC. The provider was taking action to address this issue.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. Staff had received DoLS training. A DoLS tracker provided oversight and monitored the progress of applications. DoLS had been applied for, however, no authorisations were in place.

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.

The provider ensured support was safe and fully met people’s needs, while also enabling people to do the things that mattered to them. Staff worked closely with people to help them understand and manage risks. Risk assessments guided staff on how to support people safely and were reviewed frequently.

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

The environment was well maintained. Up to date safety certificates were in place and compliance checks were carried out to ensure the safety of the building and equipment.

The bedrooms were well equipped, with 2 rooms fitted with ceiling-track hoists extending into en-suite facilities. Concerns were discussed regarding the absence of a call bell system throughout the service. While staff completed regular checks and observations, people were unable to independently summon assistance when in their bedrooms, en-suites, lounge, or dining areas, as call bells were only available in the communal accessible toilet and communal bathroom. This limited people's ability to promptly alert staff when support was required. The provider agreed to review this and take action to ensure people’s safety.

We identified emergency information, including Personal Emergency Evacuation Plans (PEEP) and hospital passports, was not in place in the fire grab bag for everyone who was staying in the service. The manager took immediate action to address this and implemented lessons learned to ensure this information was kept up to date.

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.

Flexible staffing systems were in place, which were monitored and reviewed by the manager. Staff deployment was planned around people’s needs and daily activities, which staff told us worked well. Effective on call systems were in place to support staff out of hours and at weekends.

Records showed the majority of staff were up to date with mandatory training and, where there were shortfalls, action was being taken to ensure compliance. A significant number of staff were not up to date with practical moving and handling training. This had been identified by the manager and training took place during the assessment. The manager had recently implemented performance development reviews (PDR) with all staff. Safe recruitment processes had been followed for a recently employed staff member.

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.

The service was visibly clean and hygienic, and staff were observed wearing appropriate personal protective equipment (PPE). Records showed cleaning schedules were completed and monitored. Monthly IPC audits were carried out.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines were stored safely and securely with appropriate temperature monitoring, and stock was well managed. Staff received medicines training and competency checks. Audits were carried out regularly and appropriate actions taken.

Effective systems were in place for recording medicines coming in and out of the service. Medicine administration records (MAR) were well completed, although some gaps were noted on cream administration records. Protocols were in place for ‘as required’ medicines and work was in progress to make them more person-centred. The manager ensured people had annual health checks.