Walsingham 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 inspection we rated this key question requires improvement. At this inspection the rating has remained 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.

This service scored 59 (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. Lessons were not always learnt to continually identify and embed good practice. During our inspection, we identified some areas where the provider’s policy or safe practices were not always followed. For example, the provider had not consistently embedded robust checks on the safety and quality of the service following feedback from our last inspection. This meant we continued to find similar issues to our last inspection.

Staff listened to concerns about safety and investigated and reported safety events. For example, any incidents or accidents were reported and risk management plans reviewed to minimise risk of reoccurrence.

The registered manager told us they had previously been unaware of changes to fire safety regulations, and this had resulted in an enforcement notice from the fire service. Immediate actions had been taken to address the shortfalls in safety. The registered manager reflected their learning had ultimately been a positive experience. With consent from the provider, the fire service used the home as a ‘case study’ so others could also learn.

Throughout this inspection, the registered manager was receptive to feedback, demonstrated an openness and honesty and was willing to act on areas needing improvement.

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 registered manager told us where planned moves between services happened people were invited to visit the home and assessments were made as to whether people would be compatible to live together. However, on rare occasions unplanned moves between services took place due to immediate changes in people’s needs. During our inspection, we saw the registered managed handled an unplanned move in a calm way, involving the person, social care professionals and care staff, with as little disruption as possible to people living at the service. This ensured people continued to receive the care and support they needed.

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. The provider shared concerns quickly and appropriately, should they occur.

We spent time with people living at the home and saw they were relaxed with staff members, enjoyed their company and chatting together. One relative told us, “[Name] is the happiest they have been in their lifetime now they are living at Walsingham House. I have no concerns about their safety there.” Staff demonstrated they understood their role in protecting people from the risks of abuse and were able to tell us what actions they would take in the event of having concerns. Where concerns had been shared by staff to the registered manager, these had been acted on in a timely way, involving other healthcare professionals where needed.

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.

Since our last inspection, improvements had been made to people’s risk management plans. They contained the information to staff needed to manage identified risks and reduce the risks of harm or injury to people. Staff knew people well and how to communicate clearly with them to reduce risk. For example, we saw 1 staff member supporting a person to use the stairway chair lift. This staff member ensured the safety belt was attached and spoke with the person as the chair lift descended the stairs. On getting off the stair lift, the staff member gently directed the person how to safety step off and away from the seat, before mobilising to the lounge. The staff member then immediately stowed the chair lift to its safety position.

The provider detected and controlled potential risks in the care environment and made sure facilities supported the delivery of safe care.

Following our last inspection, improvement had been made in undertaking fire-based scenario drills. Staff were able to tell us the action they would take in an emergency and a need to evacuate the home.

People had personal emergency evacuation plans (PEEP)s and staff knew what support individuals would need in the event of an emergency. We saw the stairway had a chairlift fitted, which meant the stairs was very narrow. We discussed 1 person’s PEEP with the registered manager due to our concern about how this person might safely manage the stairs in an emergency. The registered manager assured us this person chose to take part in safety drills and with staff support managed the stairs in a safe way.

Following an incident where 1 person, with a deprivation of liberty in place, had left the service unaccompanied by staff, the provider had taken action to ensure the front door of the property was alarmed to alert staff if the door was opened. This ensured people could freely move about the service they were living in, but staff would be alerted if the front door was opened.

Most premises and safety checks had been recorded as being completed and staff told us they could report any concerns if needed. However, not all documents related to checks could be located by the registered manager on the day of our inspection, for example legionella testing. The registered manager assured us this had been completed and reflected that they needed to be more organised with paperwork at their office.

The provider had processes in place for the safe recruitment of staff, but these were not always followed, which posed potential risks of staff not being recruited safely.

We looked at 3 staff files and found gaps in the information in all files. For example, 1 staff member had commenced working at the home before their DBS (Disclosure and Barring Service – a background check used by employers as part of the recruitment process) had been received by the provider. There was no risk management in place to support why this decision had been made. One staff member’s employment history was incomplete and 1 reference on file did not relate to any previous employment listed or referee’s named on their application form. We queried a screen shot of a ‘WhatsApp’ message being accepted as a reference and the registered manager told us they were unaware of it, and it should not have happened.

While we found improvements were needed in the safe recruitment of staff, we found people had been harmed as a result of the gaps we identified. All 3 of the staff files we reviewed, at the time of our visit, now had a current valid DBS in place. The registered manager assured us a full check of staff files would take place and any gaps in information addressed.

When we asked to look at staff’s induction records, a staff member told us, “This is the induction booklet for the newest member of staff who started in July.” We found the booklet to be blank with no record of their induction being completed or their competencies assessed prior to working unsupervised. During our visit to the provider’s administration office, (off site from the service), we found 2 further staff files had no record of induction. Whilst staff assured us, they had received an induction, with 1 staff member telling us, “I always buddied up with an experienced staff member for the first month, I was well looked after and have completed my training,” improvement was needed to ensure staff inductions were fully documented.

There was no system in place to assess and record staff’s competencies to ensure they had and continued to have the skills needed for their job roles. For example, staff completed moving and handling training, but no competency assessment took place in the home to assess they put their learning into safe practice when using people’s individual moving and handling equipment. The registered manager told us a competency check would be implemented.

Staff told us they felt the training given to them met their needs. One staff member told us, “We just literally did catheter care update training yesterday and it is really useful, so we know what to do and how to problem-solve issues.” Staff told us they had opportunities to have supervision meetings and appraisals.

People, relatives and staff felt there were enough staff on shift. One staff member told us, “If we are short-staffed, we occasionally use agency.” Agency staff profiles were in place and checks had been completed on them to ensure they had the skills needed.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

On arriving at the home, we saw a yellow clinical waste bin was overflowing and on the front lawn. We discussed this with the registered manager who told us, “It was due for collection, but they won’t take it because some items are not bagged properly in the bin.” When we left the home, the bin remained on the front lawn, and no action had yet been taken to ensure items had been correctly bagged.

The registered manager had delegated checks on infection prevention to care staff. During our inspection, we identified a few areas that needed improvement that checks had not found. This included hand soap and a foot-pedal operated bin being made available in a shared toilet facility. We found a few food items in the fridge that were either not labelled or should have been disposed of. Immediate action was taken during our visit to address these shortfalls. The registered manager told us they would increase their oversight of checks made to ensure a high level of infection prevention and control was consistently maintained.

The home was clean, and staff had been trained in infection prevention and control. Overall, staff demonstrated infection prevention skills in their work. The registered manager told us they would remind staff about correctly bagging clinical waste items and ensure the bin was not stored on the front lawn of the service, unless being collected that day. Staff had access to personal protective equipment (PPE) which they used when supporting people with personal care.

Overall, the provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. However, some improvements were needed to ensure staff consistently had the information they needed and that checks on staff’s competencies in the safe handling of medicines were robust and recorded. Also, that medicines awaiting safe disposal were handled safely and followed legal requirements.

At our last inspection, we had found that body maps were not in place for staff to refer to, when needed, to inform them where topical creams should be applied onto a person’s skin. At this inspection, whilst we found blank copies of body maps were available for use, staff had not completed these. However, risk of error in the application of creams were minimised because staff knew people well. The registered manager told us whenever agency staff were used at the service, they did not administer any medicines or prescribed items to people. However, the registered managed added that the body maps should be in place and would be implemented.

The temperature of the medicines stock cupboard was checked by staff, but these checks were not robust because the thermometer used was not digital and gave very limited information. Whilst temperatures recorded had not exceeded 25 degrees Celsius, staff could not record the high and low temperatures over a 24-hour period. The registered manager told us they would ensure a replacement was put into place.

Staff had been trained in the safe handling of medicines and records showed people were supported with their medicines in a way that met their needs. However, the provider had no system in place to regularly assess staff’s competencies in the safe handling of medicines. The registered manager told us new staff were informally observed by an experienced staff member who had completed the same level of training rather than having a higher level of expertise.

The service had secure storage available to some medicines requiring tighter controls legally. However, this secure storage had not always been used, and the registered manager had not always followed safe practice in storage or legally required records for such medicines. We have further reported on this in the well led section of this report.