Walton Manor

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. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment, safeguarding service users from abuse and improper treatment and staffing.

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 based on openness and honesty. We found the service did not implement learning following complaints at the service. Upon review of complaints received by the service, we found concerns which had already been identified through previous complaints and where improvements should have been made. This included staff not always recording where people received, were offered or may have refused personal care, call bell alarming for long periods and concerns with people’s laundry. Even though there was some analysis of accidents and incidents, the provider could not demonstrate that that incidents were always promptly investigated. We found there was sometimes a delay in when incidents were actually reported to the managers which meant investigations to prevent reoccurrence were not always timely.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The 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.All the people we spoke with felt they were safe living at Walton Manor. One person told us, “Oh yes I feel very safe, it’s lovely here.” However, we found safeguarding concerns which had not been reported to the local authority. We also received feedback from partners that a safeguarding referral had not been reported to them after a person had sustained an injury. Upon review of people’s care records, we found people were being deprived of their liberty without appropriate authorisations in place. The service was aware of this and took action to address this by submitting appropriate Deprivation of Liberty Safeguards (DoLS) authorisations following our site visits. The concerns demonstrate a breach of Regulation 13 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider worked well with people to understand and manage their risks. There were systems in place to identify and mitigate the risks to people’s care and support. People who presented risks had equipment in place which was being used in different areas of the homes, for examples sensors and pressure relieving cushions. Overall, staff had good knowledge of people’s risks and knew how they were managed. We found some mattresses where not at correct settings for people who presented with the risk of pressure sores. Staff took prompt action to address this alongside relevant professionals.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. There were effective systems in place to monitor and regularly check the safety and upkeep of the premises.Safety checks were completed daily and weekly in all areas of the home to ensure safe systems were in place. These included water temperatures, fire safety checks and kitchen equipment.Equipment used to support people was suitable, well maintained and stored securely.People’s bedrooms were personalised with photographs and items belonging to them.

The provider did not always make sure there were enough staff to ensure people received care to meet their individual needs. The provider could not demonstrate that there was a system in place to determine the number of staff needed on shift to meet people’s needs effectively. The information we reviewed did not contain up to date information about the number of people at the service. We received consistent feedback from staff about the staffing levels. Staff felt there were not enough staff on shift to meet people’s needs and keep them safe. Staff we spoke with reported that they had shared these concerns with the managers, but no action had been taken. Staff shared examples of when people were left waiting for care as a result of less staff on shift. We were informed that at least 1 staff member needed to remain in the communal areas to attend to people. However, during our visits, we observed communal areas without any staff as they were attending to other people in the service. This was consistent with the feedback we received from staff that they were not always able to keep people safe when they had to leave the communal areas to attend to other people. Relatives shared positive feedback about staff, but they also felt there were not enough staff on shift. One relative said, “There aren’t always enough staff especially if staff are poorly or holiday times.” As part of the assessment, we reviewed staff training records found a significant number were not up to date with their training required for their role. The concerns demonstrate a breach of Regulation 18 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider assessed and managed the risk of infection. They detected and controlled the risk the spread of any infections. The provider had an infection control policy for staff to follow. The home appeared clean and well maintained. There were no unpleasant smells. Cleaning staff were operating around the home. Everyone that was able to respond felt the home was clean. We observed staff wearing Personal protective equipment appropriately.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning. Care records were not always completed accurately. Staff did not always record when prescribed topical creams had been applied for people. Medicines were not always administered as prescribed. For 1 person we saw that the required gaps between doses were not always followed so they received doses of paracetamol too close together which placed them at risk of overdose. Another person had an antibiotic given for longer than the prescribed dose, with nothing recorded in the notes to explain why. This meant it was not clear whether people received their medicines as prescribed. Instructions for medicines that were given when required did not always contain person centred information. For 1 person we saw incorrect information in their protocol which was prescribed medicines to manage their agitation, there was not always information documented on incidents that led to the use of the medicine or actions to take to prevent its use. Staff did not always have the information they needed to administer medicines safely or as prescribed. Medicines were stored securely and managed by staff who had been trained and had their competency assessed. Areas used to store medicines were being temperature monitored however there was not always evidence of any action taken when temperatures had been recorded as being outside of the recommended range. People were supported to manage and self-administer their own medicines if appropriate and risk assessments were completed. Although the service was conducting their own audits, these had not always picked up on the issues seen on the inspection. The concerns demonstrate a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.