Wilton 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 inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to managing risks, medicines, IPC and premises and equipment.

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 always have a proactive and positive culture of safety based on openness and honesty. The management team did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. There was a lack of robust systems in place to enable the provider to have effective oversight of accidents and incidents, or to learn lessons from them. We found several accidents and incidents which were not appropriately dealt with, recorded or reported externally. For example, where people had behavioural incidents, there was a lack of detailed reports, and not all incidents were reviewed as part of monthly oversight. We also found a lack of seizure monitoring. Seizures were not always included on monitoring records.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. Whilst we found staff worked closely with a range of health professionals, such as district nurses, GP's and speech and language therapy (SALT) teams. We could not be assured the service provided external agencies with robust and up to date records. There was a lack of robust care plans in place to manage people's conditions, and we found some records lacking information from external professionals. For example, 1 person's care plan did not contain their SALT information and another person's record lacked detail about pressure care advice. We also found 2 incidents of delays in staff contacting medical services.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Whilst people told us they felt safe living at the service, we found several safeguarding concerns which had not been reported externally as required. We found a lack of appropriate recording and a lack of oversight, meaning not all safeguarding concerns were reported to the local authority or CQC. For example, an altercation between 2 people living at the service was not recorded, reviewed, actioned or reported. Following our assessment, we referred several incidents to the local authority safeguarding team. Staff were trained in relation to safeguarding and told us they felt able to whistle blow on poor practice. A staff member said, “I have never had to report anything, if I did need to I would report this to the manager but have never had to. People are safe, absolutely.” However, this training had not been effective at ensuring incidents were recorded, reported or escalated appropriately.

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. There was a lack of robust records relating to people's health conditions, and a lack up to date guidance for staff to follow. For example, we found a lack of risk assessments and care plans for managing a person's pressure care, and we could not be assured this person received regular repositioning to manage their pressure wound. There was a lack of robust information relating to managing epilepsy, oedema and mobility needs. There was a lack of detail about how staff supported people with their mobility, for example, 1 person's care plan did not detail what equipment they used, sling details or step by step guidance about how staff safely transfer. We found care records relating to pressure care, epilepsy, choking and behaviours of concern to be conflicting and lacking detail.A person who required their legs elevated to manage their oedema was found not to have their legs elevated on 3 occasions throughout our assessment. The provider told us this person did not wish to have their legs elevated. However, as there was a lack of care planning about this condition, it could not be evidenced what this persons regime should be, or any information for staff about repeated refusals. Where people displayed signs of distress, there was a lack of information in people’s care plans, to enable staff to support people during these incidents. Staff did not always record people's behavioural incidents appropriately, we found several records which did not contain enough detail about how people presented and how staff should respond. People’s care plans did not always contain enough information about managing people’s risk of choking.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, and facilities supported the delivery of safe care. We found items unlocked which could pose a risk to people living at the service. We found 3 cupboards containing COSHH items to be unlocked across the homes, unlocked sheds and garden storage units containing garden chemicals. We found plumbing concerns to an upper floor in 1 house, which meant there was a strong malodour to this area, which contained people's private bedrooms. We were informed following the assessment that this had been fixed. We also found several areas with trailing wires which could pose a trip hazard to people. Two people using the service had a change in mobility needs, meaning they could not access their own bedrooms to upper floors. The provider had recognised this concern and was working with the local authority to look at alternative placements. However this was ongoing, and these people were residing and sleeping in communal rooms downstairs. We contacted South Yorkshire Fire service to share our concerns, who visited the service following our assessment. Temporary measures have since been put in place to mitigate risks posed to people regarding fire safety; however, this was not considered prior to our assessment and internal fire safety risk assessments lacked detail about this concern. We also found 2 people had out of date personal evacuation plans, which did not include their presentation and health condition. We found risks posed to people from legionnaires disease were monitored and mitigated and electrical and lifting equipment checks were in place.

Staff were trained in a range of subjects and training compliance was high. However, we found staff had not received up to date training or competency assessments relating to diabetes management. People were supported by enough staff; however, we found 1 person was left alone at times, despite receiving 1:1 support. Staff were recruited safely, and all pre-employment checks were in place. New staff received inductions. Staff received regular supervisions, and staff told us they felt supported in their roles. A staff member said, “Manager is lovely, all the team leaders are very supportive, can talk to them, they help us to deal with things.”

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. Systems in place were not effective in managing risks posed to people from infections. Several areas of the service were found to be visibly dirty, for example, we found bathrooms which were visibly dirty, limescale on taps, dusty skirting boards and flooring which required hoovering. Several furniture items were ripped, and we found several outside bins to be broken, including a clinical waste bin. Toilet rolls were stored inappropriately, and we found some paper towel dispensers to be empty. Several items in fridges did not contain open date labels and we found a person had made a sandwich using out of date meat. We were told by the provider this person did not ingest this. We also found several hand gels to be out of date. These were immediately removed by the registered manager. The provider told us following our assessment these hand gels had been refilled from a larger tub. However, the hand gels spouts were visibly dirty, and it is not best practice to refill hand gel bottles due to a risk of cross contamination.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Whilst we found medicines administration records (MAR’s) to be complete and ‘as required medicines’ protocols in place. We could not be assured medicines were stored appropriately. We found some medicines storage areas to be hot and an incident where staff had moved medicines to an unlocked cupboard. We found an unlocked fridge in a communal kitchen, containing insulin. We also found a person who had paracetamol stored in an unlabelled box. We found staff were supporting a person to manage their insulin injections. Whilst this person self injected, staff supported them with dosages and recording. We found creams stored in people's rooms with no open date labels and some out-of-date creams in people's rooms.