Welbeck 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 remained 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.

The provider’s systems for reviewing accidents and incidents were effective. Accidents and incidents were recorded, investigated and analysed, and lessons learned were used to drive improvement. Staff meeting minutes demonstrated this learning was shared with staff teams to reinforce best practice and highlight what could have been done to reduce the likelihood of reoccurrence. The registered manager told us when a person experienced a fall, they carefully reviewed the circumstances before, during and after the incident, including where staff were positioned at the time and any environmental or care factors that may have contributed. This reflective approach supported a positive learning culture, with a clear focus on preventing future falls and improving people’s safety.

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 provider had effective systems in place to assess people’s needs and support them safely. People’s needs were assessed before they received a service, and these assessments informed personalised care plans and risk assessments. The registered manager told us assessments were completed face to face and involved people, their relatives and relevant health and social care professionals and records confirmed this.

Systems were in place to identify and respond to changes in people’s health needs, with timely escalation to appropriate professionals. External professionals, such as district nurses and case management teams, were involved in monitoring and reviewing ongoing clinical needs.Communication and hospital passports were used to support safe transitions between services. These contained key information about people’s needs and routines to support continuity of care. Staff supported people to attend appointments and hospital admissions to promote safety and reassurance. People and their relatives told us they were kept informed of changes to care plans.

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.

People told us they felt safe receiving support. One person said, “I feel safe here.” Staff understood how to recognise and report abuse and had completed safeguarding training. A safeguarding tracker was in place, and the registered manager reported concerns to the local authority as required and took appropriate action to protect people. When concerns were raised the registered manager worked proactively with relevant agencies. Safeguarding concerns were monitored for themes and trends, and learning was shared with staff to support continuous improvement.

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.People told us they were supported to manage their safety. One person said, “I can’t get up so staff help me get up.” Staff understood people’s individual risks, including anxiety, and knew how to recognise signs of distress and provide reassurance to keep people calm and safe.

Risk assessments were in place, regularly reviewed and embedded within people’s care plans. These included assessments for nutrition, hydration and Personal Emergency Evacuation Plans (PEEPs). Identified risks were supported by clear management plans with actions to reduce risks and promote positive outcomes.

Staff were knowledgeable about the risks associated with the people they supported and understood how to mitigate them. Staff told us risk information was clear and provided sufficient guidance to deliver care safely. For example, where people had specialised diets, staff were aware of people’s dietary needs and how different types of food made people feel. Risk assessments and management plans were reviewed routinely and updated to reflect changes in people’s needs, ensuring people remained involved and supported to manage their safety.

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

People and relatives told us staff maintained a safe environment. People said their homes and bedrooms were always clean and well maintained. We observed that the home was clean, free from odours and trip hazards, and that environmental safety measures, such as window restrictors, were in place. Fire risk assessments had been completed, and fire drills were carried out regularly. Staff told us they felt confident in supporting people to evacuate safely if required. All staff had completed fire safety training. Regular environmental and health and safety checks were completed, with any identified actions addressed promptly. Records confirmed that gas, electrical, portable appliance and water safety checks were up to date. People were supported to personalise their rooms in line with their preferences, helping them feel comfortable and safe within their own environment.

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.

Staff were recruited safely. This included checking their identity, their eligibility to work in the UK, obtaining at least 2 references and Disclosure and Barring Service (DBS) checks. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Staff had regular supervision and opportunities to meet with managers to discuss their role, performance and training needs. Staff had received training appropriate to their roles to support people safely.Our observations showed staff were prompt and responsive when providing care and support in communal areas. Staff told us there were sufficient staffing levels, and people said staff listened to them and responded to their requests. There were enough staff on duty to support people safely and to enable them to take part in activities both within the service and in the local community.

There was a strong learning culture within the service, with staff encouraged to undertake additional training to build on their qualifications for better opportunities. The registered manager told us a training matrix was used to monitor completed and upcoming training. Records confirmed staff had completed all mandatory training, with no gaps identified, including safeguarding, medicines administration and infection prevention and control.

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.

People and relatives told us staff wore Personal Protective Equipment (PPE) and staff disposed of it themselves. The provider had a policy in place for Infection Prevention Control (IPC). IPC audits were completed monthly. The provider’s training matrix showed staff had received IPC training and staff told us they had access to PPE. The registered manager also told us that staff were required to complete mandatory IPC training. This training helped ensure staff understood how infections can spread and what actions they must take to reduce risks to people using the service. Mandatory training was designed to support staff to follow best practice and comply with the service’s infection control policies and procedures.

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

The provider’s systems for medicines management were not fully effective. We found discrepancies between medicines stock levels and medicines administration records, which had not been identified by existing monitoring systems. This meant the provider could not be assured people were always receiving their medicines as prescribed. In addition, some prescribed creams were not stored in a dedicated medicines fridge of a suitable standard to ensure medicines were maintained at the correct temperature. Following our site visit, the registered manager has informed us a suitable fridge has now been installed.

Although medicines audits were carried out regularly, these had not identified the concerns we found during inspection.

However, people told us staff supported them with their medicines, which they were happy with, and relatives confirmed this. Where people were prescribed medicines on an ‘as required’ (PRN) basis, clear guidance was in place to support staff to administer these safely and appropriately. The use of PRN medicines was monitored and reviewed to reduce the risk of over‑medication.

Staff administering medicines were trained and had their competency assessed before supporting people. Regular competency checks were in place. People received regular medicines reviews from health professionals to ensure their medicines remained safe and effective. Medicines were stored securely and only administered by suitably trained staff.