Whitgift 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. The provider had processes and systems in place; however, they did not always follow their own procedures to ensure people were always kept safe.

The provider was in breach of legal regulation relating to safeguarding people from abuse and there was an increased risk that people could be harmed.

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 had a limited learning culture, and systems to learn from incidents and embed improvement were not consistently effective. Lessons were not always learnt to continually identify and embed good practice. Leaders described plans to share learning through meetings; however, these systems were newly introduced and not yet embedded.

Although electronic care systems captured incidents, we did not see evidence of analysis of trends or how learning was used to reduce future risks. Systems for governance and oversight used both paper based and electronic systems, and the new manager had limited access to systems at the time of inspection. For example, falls were reported on the electronic case record, and actions were put in place to manage individual risk. Whilst we saw evidence of learning from individual events there was no evidence of management oversight of any themes or trends, for example to analyse the falls data to identify system improvements and share these consistently with staff.

There were also gaps in audit processes, including incomplete records and inconsistencies in oversight of actions arising from incidents and audits. This meant opportunities to learn and improve safety were not always identified or acted upon.

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The provider did not consistently operate safe and effective systems to manage admissions, transitions and care pathways.

Inspection findings identified that some historical admission decisions had been made without sufficiently robust processes in place to assess compatibility or ensure that people’s needs could be safely and effectively met. This meant that, at times, placement decisions were not underpinned by comprehensive assessment or multi-disciplinary input, which increased the risk of people receiving care in environments that may not have been fully suitable to their needs.

At the time of inspection, the provider had recognised these shortfalls and had begun to implement a revised admissions process. This included the development of more structured assessment arrangements and the introduction of staff training to support improved decision-making. However, these arrangements were not yet fully embedded in practice.

Feedback from external professionals indicated that the service was responsive and worked collaboratively with partner agencies. Despite this, systems to ensure consistent oversight, governance and safe management of care pathways remained under development. The newly appointed manager had identified this as a priority area and had established a plan to strengthen multidisciplinary involvement and improve the robustness of admission and transition processes, although these improvements had not yet been fully realised at the time of the assessment.

Systems and processes to safeguard people from abuse were not always effective. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

While staff understood how to recognise and report safeguarding concerns, and had received training, oversight by the provider was inconsistent and we found gaps in reporting and records.

We found concerns in relation to statutory notifications, where safeguarding incidents had not been consistently reported to the regulator as required. This demonstrated gaps in governance and oversight of safeguarding processes including safer recruitment practice. We found that systems were not yet embedded to ensure consistent safeguarding practice and oversight. The manager understood and had experience in formal safeguarding processes, and what is needed. A new safeguarding policy was in place but needs time to be embedded in practice.

Systems and processes were not robust or operated effectively to safeguard people from the risk of abuse. Therefore, people were not adequately protected from potential abuse.

This was a breach of the legal regulation relating to safeguarding.

Applications had been made for Deprivation of Liberties Safeguards (DoLS) and best interest decisions were documented. DoLS protect the human rights of people who cannot consent to care that restricts their liberty.

The provider involved people in managing risks to their safety. Care records showed detailed risk assessments and care plans that reflected people’s individual needs and preferences.

Risk has been assessed to people and measures to reduce these have been identified and recorded and are reviewed regularly. People’s information was person-centred and reflected their needs and wishes, likes and dislikes and preferences for how care and support should be provided to people.

People told us they felt safe and supported by staff, with one saying, “I feel very safe here… they are careful about safety.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

While parts of the home were clean and well presented, we found several environmental risks. Fire safety systems were not robust. Whilst personal emergency evacuation plans (PEEPs) were updated in people’s care records the paper records kept in case of an emergency evacuation, were inaccurate, undated and included records for people no longer living at the home, which could place people at risk in an emergency. Evacuation equipment was not consistently accessible, and key information for the emergency services was not up to date. These risks were discussed with managers on the day and have since been addressed.

Other concerns included a lack of signage due to redecoration, unlabelled hazardous storage, and cluttered or poorly maintained areas. These issues meant the environment did not consistently support people’s safety.

The provider did not consistently ensure there were enough suitably qualified, skilled and experienced staff deployed to meet people’s needs. Systems to support staff supervision and development were not consistently implemented, and staff did not always work effectively together to deliver safe, person-centred care.

Feedback from people and staff consistently highlighted concerns about staffing levels, with reports of delays in responding to call bells and delivering care. People and relatives raised concerns about staffing levels. A relative told us “At certain times of the day, like mealtimes and bedtimes, they are busy. My [relative] has to be hoisted and has to wait for 2 people; it can be busy at times.” Another relative said “Sometimes, they can be a bit pushed, if there is a lot who need help, it depends on what they are doing”.

The provider used a dependency tool which assessed people’s needs and informed staffing levels based on those needs. The provider’s view was that it was an effective tool and current staff numbers were meeting people’s needs.

Although staff had access to training, supervision arrangements were not always consistent. Some staff received regular supervision, while others did not. This meant staff were not always appropriately supported to reflect on practice and safeguarding processes, maintain competence and deliver safe, effective care.

These issues meant staffing arrangements did not consistently support safe and effective care.

The provider had systems in place to manage infection prevention and control (IPC); however, this required improvement to ensure they were fully effective.

The home was generally clean, and staff followed infection control practices, including the appropriate use of personal protective equipment (PPE). We observed regular housekeeping including cleaning activity taking place during our inspection.

However, we identified some concerns. These included empty hand sanitiser dispensers and areas of the home which required more thorough cleaning and redecoration. Although audits were completed, it was not always clear how identified actions were monitored to ensure they had been addressed and sustained.

Overall, IPC systems were in place, but oversight was not consistently effective in maintaining required standards.

People told us they were satisfied with the cleanliness of the home, and the provider had plans in place to carry out redecoration.

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.

We observed appropriate systems for storage, administration and recording of medicines, including the use of electronic medication records and regular stock checks.

Medicines were stored securely, and processes were in place to check temperatures and ensure safe handling. People told us they received their medicines as expected, and no concerns were identified during inspection.