Archived: Wolverley Court Residential Care Home

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.The service was in breach of legal regulation in relation to safe care and treatment, safeguarding, and medicines management.
 

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People continued to be at risk of harm due to the provider's lack of systems to learn from incidents, meaning care and support didn't always adapt or respond to known risks and incidents. The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. Systems and processes were not in place to support the service to learn from incidents. We found safety concerns, detailed in the body of this report, which had been identified by the local authority on a previous quality monitoring visit. The provider had not acted upon and learnt from feedback given by the local authority.

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.
The provider did not ensure safe and effective systems were in place to support people when moving into or between services. Staff did not complete pre-admission assessments before people moved in, which meant the provider could not confirm whether admissions were appropriate or met individual needs. Although staff obtained assessment paperwork from social workers and 1 relative confirmed they had taken their family member to visit the service beforehand, this did not replace a thorough pre-admission process. Prior to the inspection, healthcare professionals raised concerns about how staff communicated and worked with them. People did not have hospital passports in place which enable sharing of key health and personal information to support smooth transitions between services. Additionally, people and relatives told us they had not received a service user guide, which should inform them of their rights, what the service offers, and how to raise complaints.
 

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. They did not share concerns quickly and appropriately.
The provider did not ensure people received their medicines as prescribed. For example, 2 people were prescribed pain relief. We found there were gaps in the Medication Administration Records (MAR) for both people. This meant there was risk their pain was not being managed effectively.
One person required their food prepared to a specific consistency to reduce the risk of them choking. Food input charts indicated that people may have been given food that was not prepared in line with their assessed dietary needs. Staff had not received training on how to prepare meals in line with the International Dysphagia Diet Standardisation Initiative (IDDSI). This placed people at an increased risk of choking and avoidable harm.
Staff did not always work in a way that protected people from harm. Inspectors observed a person being transferred in a wheelchair without footplates. Footplates are used to reduce the risk of entrapment and injury. The inspector intervened and asked the staff member why they were transferring the person unsafely. The staff member explained they were following instructions given by the manager. This response indicated a closed culture, where unsafe practices were normalised and staff felt unable to challenge poor guidance, placing people at risk.
Leaders and staff did not share concerns appropriately. Incidents had not been reported to the local safeguarding authority or CQC as required. This meant people were placed at continued risk as investigations had not taken place to prevent recurrence.
The registered manager managed 1 person’s finances, however there were no records on site for us to review. As a result, inspectors were unable to confirm whether the person’s finances were being handled appropriately. The lack of transparency and accountability raised concerns about the safeguarding of the individual’s financial wellbeing.
We raised several safeguarding referrals in relation to the concerns we identified during our assessment.

The provider did not work effectively with people to understand and manage risks. Risk assessments were either not in place or lacked essential details. For example, how health conditions affected individuals or how staff should respond. Risk assessments were not consistently reviewed or did not involve people in the process, meaning records did not reflect people’s needs or wishes. Fire risks associated with paraffin-based medicinal creams which can accumulate on fabrics and increase flammability had not been identified or assessed appropriately. This meant steps to reduce the exposure of risk of harm to people were not taken. There was also a failure to assess and manage risks linked to bed rail use, increasing the likelihood of entrapment or injury. One person’s care plan noted they suffered with constipation but did not refer to any medicines they were taking to manage this or when medical attention should be sought. This meant there was a risk people were being exposed to the unnecessary risk of harm, and opportunities to take actions to mitigate risk were missed.

The provider failed to detect and control environmental risks, compromising the safety of people using the service. Prior to our assessment we were made aware of concerns by the local authority regarding the environment. During our assessment we identified environmental safety concerns remained. For example, we observed one person’s bedroom door held open with a wooden wedge and shelving obstructing a fire exit in the kitchen. There was no evidence of regular fire drills taking place.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.
When we arrived on site there were 2 members of care staff on duty. We asked them to tell us about the 3 people currently living at the service. Staff gave limited information and showed little understanding of individuals’ needs and medical backgrounds. They also confused details between people, which raised concerns about the accuracy of their knowledge.
They were unaware if any other colleagues were scheduled to work that day, and rotas were not available for us to review. During our visit, no additional staff such as activities coordinators, domestic or catering staff were present. Therefore, care staff were responsible for other tasks including meal preparation, cleaning and laundry. The registered manager was not on site during or visit but was contactable by phone.
There were no training records for us to view and there was no evidence of staff receiving any form of induction. Staff had received training from other services, however, there was no evidence of this, and the provider had not undertaken any competency assessments to ensure staff had the required knowledge and skills to provide safe care. These omissions placed people at risk of harm and demonstrated a lack of safeguarding awareness across the service.

The provider did not always assess or manage the risk of infection. We found that staff had not carried out any infection prevention and control (IPC) audits, to ensure the safety and well-being of people living at the service. We were not assured staff had received IPC training due to the absence of training records. We found several fridge items were not labelled with their opening and use by dates. This meant there was a risk these items would be used past their recommended shelf lives putting people at risk of potential food poisoning. Food items were not stored in airtight containers which increased the risk of contaminated food being eaten.

The provider did not manage medicines safely. Inspectors found controlled drugs were not securely stored in line with best practice. These drugs, which are regulated due to their potential for misuse or addiction, should be kept in a controlled drugs cupboard with records maintained in a controlled drugs register. On the day of our visit, the staff member responsible for administering medicines did not know where the controlled drugs were stored and had to contact the registered manager. Inspectors found the drugs left on top of a cabinet in a person’s room, and no register was in place.
People did not receive their medicines as prescribed. For example, 1 person was not given medicines to treat their health condition as it was prescribed. Between the period of 1 June to 29 June 25 there were 25 missed doses of their medicine being administered. This increased the risk of a relapse of their health condition. Medicinal creams were not dated or a record kept of when and where creams should be applied.
Staff did not complete MAR in line with the National Institute for Health and Care Excellence (NICE) guidance. We found some handwritten MAR charts lacked the dose or amount of medicine to be administered. A second member of staff had not checked these charts to confirm the administration details were correct. This placed people at risk of receiving the wrong dosage of medicines. We also found failure to carry out stock checks consistently. During our assessment, we completed some stock checks and identified discrepancies in the amounts for certain medicines. As a result, the provider could not confirm that people had received the correct medicines.
Staff did not have any guidance to inform them how and when to administer ‘as required’ (PRN) medicines safely. This failure placed people at risk of having their health conditions managed ineffectively.
Staff did not record when people declined to take their medicine. They did not communicate with external health support, such as the GP, when people refused their medicines regularly. This meant there was an increased risk of people’s health conditions not being treated or monitored correctly.