Weaver 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. This is the first assessment for this service. This key question has been rated as good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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. Lessons were not always learnt to continually identify and embed good practice.

The provider did not always demonstrate that lessons were promptly learnt from previous incidents or clearly evidence what actions were taken as a result.

The manager told us, and we saw in records, that learning from previous incidents was shared in monthly team meetings. However, this meant there was a potential delay in learning from incidents being formally shared across the wider team.

Following a recent incident involving 1 person, their care plan had not been updated. There was limited information to show what had changed or how staff should support the person to mitigate future risks. After we raised this with the manager, the care plan was updated with clearer guidance for staff. Staff told us learning had been shared verbally, and 1 staff member gave an example of changes made since the recent safety incident. This helped reduce the risk of a similar incident happening again.

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.

People were supported to move safely between services. Staff received important information about people before they moved to Weaver House. This helped staff understand people’s needs and provide the right support from the start.

Before moving to the home, people could visit and get to know the environment and staff. Transitions were planned around each person’s needs. Some people made informal visits, while others had a planned transition over several weeks. This helped people become familiar with their new home prior to admission. One staff member said, “We definitely have the information we need before people move in. We also ask their families.” Another staff member said, “[Person’s name] came for tea and did an overnight. They did not need a long transition.” Staff also considered if people would benefit from changes to their rooms before they moved in. A staff member explained this sometimes helped people feel more settled in their new home.

People had emergency packs which contained important information about their needs, communication and support. These helped health and social care professionals understand how to support people when they received care elsewhere.

Staff worked directly with GPs and other health and social care professionals. They understood what information needed to be shared when people accessed healthcare or moved between services.

The provider did not always work well with people to understand what being safe meant to them and how to achieve that.

The provider did not always ensure people’s legal rights were protected when restrictions were in place. Deprivation of Liberty Safeguards (DoLS) provide legal protection for people who may be deprived of their liberty as part of their care. They help ensure restrictions are necessary, proportionate and in the person’s best interests. One person’s Deprivation of Liberty Safeguards (DoLS) authorisation had expired. For another person, the provider had not followed up their application and did not know whether it had been authorised. This meant the provider could not be assured that restrictions remained legally authorised and that people’s rights were fully protected. Both renewal applications were submitted on the day of our assessment.

Staff understood how to recognise and report safeguarding concerns and were confident leaders would take appropriate action. One staff member told us, “[Senior staff] would definitely get any safeguarding issues sorted.”

Information we had received from the provider demonstrated they understood their responsibility around safeguarding arrangements and had reported concerns appropriately, to the local authority and to us.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care records did not always accurately reflect people’s risks or provide staff with sufficient guidance to support them safely.

Changes in 1 person’s presentation were being recorded separately and were not reflected in their care plan. Managers were unaware of these records, limiting their ability to monitor changes and respond to emerging risks. The same person’s care plan stated they should receive personal care from male staff only, but staff told us this was no longer required and records showed they were supported by both male and female staff. This meant staff guidance did not reflect the person’s current needs.

However, staff understood people’s individual risks, including falls, choking, financial abuse, road safety and risks associated with underlying health conditions. One staff member described how water-based sensory activities could increase the risk of slips and falls. Staff had clear guidance on maintaining a safe environment to reduce this risk. Another staff member described previously supporting people at Weaver House who were at risk of self-harm.

Staff also recognised situations that could increase people’s anxiety and understood how to support them. For example, they helped people find personal items that were important to them and provided comfort.

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

The home was safe, well maintained and the environment met people’s needs.

People’s bedrooms were personalised to reflect their preferences. Some areas had recently been redecorated, with further improvements planned. The manager had also identified improvements to garden access for a person who used a wheelchair and action was being taken to address this.

Potentially hazardous substances were stored securely. Regular environmental checks included fire safety, water safety and window restrictors. Staff told us repairs and replacement items were completed promptly when required.

We identified a cupboard containing electrical consumer units which was not secured. Staff addressed this immediately. A gate at the side of the property was also unsecured. We asked the provider to assess this risk and keep the arrangements under review.

Fire drills were undertaken, however, records did not always show the time each drill took place. We asked the provider to ensure this information was clearly recorded so they could demonstrate drills took place at different times of the day and under different circumstances.
 

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.

There were enough staff to meet people’s needs safely. Staff worked well together and supported each other to ensure people received the care they needed.

Staff told us training supported them to provide safe and effective care, including training specific to supporting autistic people and people with a learning disability. One staff member described how training had improved their confidence in supporting a person when they became anxious. On the day of our assessment, staff were completing training on how to use Makaton. Makaton is a communication programme that uses speech together with signs and symbols to help people understand and communicate.

New staff completed induction and worked alongside more experienced staff. The provider had recently strengthened their recruitment processes, however, we identified some missing information in 1 staff file. The provider needed to further strengthen their processes for checking all required recruitment information was obtained and stored appropriately so they could be assured staff were consistently recruited safely.
 

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.

The home was clean, with cleaning schedules and records in place to support the safe management of the kitchen and food preparation. We observed staff washing their hands before preparing food and using PPE (Personal Protective Equipment) appropriately.

Staff understood how to reduce the spread of infection and told us PPE was readily available. Colour coded equipment was used in line with infection prevention and control practice.

However, some staff wore jewellery or had nails that did not meet the provider’s IPC policy. The provider identified that further oversight was needed and introduced a mandatory IPC audit to strengthen monitoring.
 

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.

The provider had systems to manage medicines safely. Medicines were stored securely and administered by staff who had completed appropriate training and competency assessments. Staff understood principles which aim to reduce the inappropriate use of psychotropic medicines for autistic people and people with a learning disability, and clear protocols were in place for medicines prescribed on an ‘as required’ basis.

People told us they received their medicines when needed. Arrangements were also in place to manage medicines safely when people stayed with family, including recording and checking medicines taken out of and returned to the home. Staff understood how to respond to medicines errors, and systems supported the safe receipt, storage and disposal of medicines.

Regular medicines checks were completed. However, these had not identified that staff did not always record the meaning of administration codes on the reverse of medication administration records. We found no evidence of harm, but incomplete records could increase risk, particularly when people moved between services. The manager gave us assurances this would be addressed with staff.