Wynhill Lodge Short Breaks Service

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 service was in breach of legal regulation in relation to people’s safe care and treatment.

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. Staff did not always record concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff did not always record all incidents. For example, a handover record showed a person had experienced a fall and “banged their head.” However, no incident form had been completed, and the registered manager was not aware that this incident had occurred. Incidents were not always reviewed or investigated to identify the root cause. This meant that opportunities for learning, reflection, and improvement were missed. As incidents where not always documented the management team did not have full oversight of the frequency or nature of events. This meant staff were unable to effectively identify patterns, trends or take appropriate action to reduce the risk of similar incidents happening again.

We did not identify any concerns in relation to a closed culture, staff feedback demonstrated the registered manager was approachable and would listen to concerns without a ‘blame culture’. One staff member told us, “I value a no blame learning culture where mistakes are used to improve practice, strengthen communication.”

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.

A professional involved in supporting a person’s transition told us, “When finding an alternative placement, I required information to help me identify the right provider. All information was sent to me in a timely manner. When it came to moving the person, [person] was transported by a staff member who knew them well, and that staff member stayed at the new placement for some time to ensure they were settled. The person has no verbal communication and relied on staff who know them well to interpret the sounds they make. Staff at Wynhill Lodge took this into account and acted beyond my expectations to support them.” This meant there were safe systems for transitions which helped reduce the risk of people’s needs not being understood or met.

The provider 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.

People can only be deprived of their liberty with the correct legal authority. In care homes, this is managed through the Deprivation of Liberty Safeguards (DoLS) under the Mental Capacity Act 2005 (MCA).

We found the service had applied for DoLS appropriately, but local authority delays meant assessments had not been completed. We also found restrictive practices in place, but the provider could not show they had followed the MCA or ensured these were the least restrictive options. For example, listening devices were used at night to monitor people, but for those people who were deemed to lack capacity MCA had not been followed and we found there were no care plans, risk assessments, or evidence of best‑interest decisions. This meant restrictive measures may have been used without proper justification, oversight, or review, posing a risk to people’s rights and freedoms.

There was a safeguarding policy in place; however, it was not always followed. We found staff did not always record incidents appropriately, and the registered manager did not have accurate oversight. Therefore, we were not assured that all safeguarding concerns were recorded, reviewed, reported appropriately, or action was taken to reduce the risk of reoccurrence.

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.

There was not always accurate written guidance in place to manage risks associated with people’s health and wellbeing, including how to support conditions such as diabetes and epilepsy. For example, one person’s care records were contradictory, one document stated they had been diagnosed with epilepsy, however another stated they had not. This placed people at risk of receiving inconsistent or unsafe care because staff did not always have accurate information to guide them.

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 service had made adaptations or provided equipment, for example there was a specialised bath in place and adjustments were made to ensure all the people they supported could move around the serviced safely. Health and safety checks were completed regularly, and there were effective processes in place to address and resolve identified risks. For example, a 5‑year fixed wiring inspection had been completed by a qualified contractor, and all identified actions were addressed in a timely manner. We observed that appropriate equipment was in place, well maintained and stored securely. There were also plans in place to carry out refurbishment work, and the service was scheduled to close for a short period to ensure the work could be completed safely. This meant people were supported in a safe environment and appropriate checks and actions were in place to ensure equipment and the premises remained safe to use.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did make sure staff received effective support, supervision and development.

Whilst there were enough staff on duty, staff had not always completed all the required training. For example, some staff had not completed dysphagia training or the required refresher courses. This meant people were at risk because staff may not have had the necessary skills or knowledge to safely support people with their assessed health needs. Staff told us they had regular one to one supervision. One staff member told us, “I have regular supervision, and I feel supported by my manager. This provides me with the opportunity to discuss any concerns, reflect on my practice, and receive guidance to ensure I am working safely and effectively.”

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.

There was a detailed infection prevention and control (IPC) policy in place to guide staff on what to do in the event of an outbreak. Staff had completed IPC training, and we observed them using personal protective equipment, such as gloves, in line with best practice guidance. People told us they could receive personal care whenever they wished, and records showed they were supported with personal hygiene in line with their preferences. One person told us, “I have a shower in my room, and I have a shower every morning.” This meant people were supported in a clean and hygienic environment, and staff practices helped reduce the risk of infection.

Medicines were not always managed safely. On people’s arrival, medicines were not always booked into the service in accordance with the services procedures or stored safely. We found a bottle of liquid medicine and a topical medicine, such as a cream, left unattended in a person’s ensuite bathroom. This placed people at risk of harm, as the products were accessible and could have been ingested by people who may be unable to recognise or understand the associated dangers.

Staff were supporting a person with insulin administration without having received the necessary training or without oversight from a suitably trained and competent healthcare professional to make sure it was delegated to them safely. This placed the individual at risk of receiving insulin incorrectly.

Medicine administration records (MARs) showed that medicines were not always administered as prescribed. For example, one person had been prescribed a cream with instructions to apply it twice daily for 7 days. However, records indicated it was administered only once daily for 2 days, demonstrating a failure to follow prescribing guidance and to maintain accurate records.