Westmoorland and Furness

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 newly registered service. This key question has been rated 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 the legal regulations in relation to safe care and treatment, good governance 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 service did not always have a proactive and positive culture of safety. They did not always investigate and report safety concerns. Lessons were not always learnt to drive improvements at the service or to identify and embed good practice.

Accidents and incidents were not always recorded or reported accurately. For example, we found that following an incident one set of notes detailed that no ambulance was called, later notes identified that an ambulance was called. Although we saw some evidence of learning from events being shared with care staff, we saw no evidence of lessons learned being undertaken to identify themes, trends or root causes, or to embed, promote and develop good practice within the service.

The provider performed their duty of candour to notify others, made timely referrals to other professionals for advice and support when concerns had been identified, and communicated updates about concerns to care staff by way of handover notes and mobile phone messaging app. The deputy care manager told us that learning following accidents and incidents were discussed with care staff during staff meetings . However, we did not find any evidence that an accident which occurred in October 2025 was discussed during the staff meeting held after this event.
 

The provider worked with people and partner organisations to establish and maintain continuity of care when accessing services.

Due to short notice discharges from hospital, or urgent requests for the commencement of a care package to start, the provider acknowledged that it was not always possible for them to pre assess peoples care needs before accepting a package of care. Wherever possible the provider completed pre-assessment paperwork before, or at the first care visit.

We spoke to eight people and/or their relatives of which six people told us that they were visited prior to their care commencing to assess their care and support needs. Two people told us that they thought they were visited prior to their care commencing.

We saw referrals were made in a timely manner, with the provider using a single point of access service for the local authority that allowed them to contact a range of other healthcare professionals for advice.

All care staff that we spoke to told us that when people join the service, the senior management team call them to discuss the person in detail prior to them visiting. A staff member told us, “The office always call me whenever there is a new client for me and tell me what I need to know.”

The provider did not always work well with people and healthcare partners to understand what being safe meant to them, and how to achieve this. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from abuse, avoidable harm, and neglect. They did not always share concerns quickly and appropriately with us.

The provider was not aware of their regulatory responsibility and that all safeguarding concerns should be notified to us. However, the provider had raised these concerns with the local authority safeguarding team, by way of referral through the single point of access service, and concerns had been discussed with a safeguarding social worker.

The provider did not always identify potential abuse as a safeguarding concern. A person using the service had reported that they experienced pain when care staff were performing moving and handling tasks with them, yet this had not been considered as a potential safeguarding concern. Care staff we spoke to could not tell us about the range of organisations that they could report safeguarding concerns to. Of the three members of care staff that we spoke to, only one was able to tell us that safeguarding concerns could be reported to the Police.

All care staff that we spoke to said they felt confident raising safeguarding concerns and were able to tell us about different types of abuse and neglect that people may experience.

All care staff that we spoke to told us that they believed that the registered manager and deputy care manager would act appropriately if they informed them of a safeguarding concern. One member of care staff told us that they had “complete faith” that the registered manager and deputy care manager would manage safeguarding concerns appropriately. Another member of care staff told us that the deputy care manager “always acts quickly” in response to any safeguarding concerns.

Improvements were required in the providers safeguarding processes to ensure that people’s safety was maintained.

The provider did not always collaborate well with people to understand and manage risk. Risks were not always managed safely, and this was because either the risk had not been identified, or that when identified risks had been identified, the plans to manage these risks were not always detailed enough to ensure that staff had sufficient information on how to manage the identified risks safely.

There were no risk assessments in place for two people taking anti-coagulation medication. A risk assessment for behaviours that may challenge, lacked detailed or sufficient information on how to manage this risk. A falls risk assessment did not contain any information on what the risk of the person falling was such as, loss of confidence with mobility, injury, or reduction in mobility. However, the provider responded quickly when we highlighted these concerns, and these risk assessments have since been undertaken.

We found no evidence that people had experienced harm because of these concerns.

The provider assessed, identified and sought to improve identified risks in the homes of people using the service. The provider made sure equipment, facilities and technology supported the delivery of safe care as far as their remit allowed.

The provider made appropriate referrals when necessary to seek support with environmental concerns in people’s homes. However, they were not always successful in accessing support for these concerns. The provider told us that requests for additional support hours to provide cleaning and de-cluttering service were refused by the local authority.

Both external and internal environmental risks were assessed, and the risks of equipment provided for use. A matrix detailing when equipment needed to be serviced was in place and the service highlighted any concerns regarding equipment or the environment to the local authority by way of the single point of access service.

The service also assessed the risk of lone working in relation to the safety of their care staff.

The provider did not recruit staff in a safe manner. They did not always make sure staff received appropriate training to provide safe care that met people’s individual needs. The provider did not always make sure that staff received effective support, supervision, and development.

The provider had not always undertaken their own enhanced Disclosure and Barring Service checks (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. Some care staff had started in their role before they had received their DBS result. Gaps in employment history on completed application forms had not been fully investigated, and no audits had been undertaken by the provider to identify to these concerns. However, when these concerns were identified to the provider during the first day of our inspection, the deputy care manager acted immediately to apply for enhanced DBS, and the results of these checks have been shared with us. The deputy care manager assured us that staff files that we did not look at during our visit would be further checked by her, and any concerns actioned.

There was no evidence provided to suggest that staff received any formal induction. However, we were told by the provider and deputy care manager that all care staff shadowed experienced and established members of the care team for a period of between 2 to 3 weeks before undertaking care duties on their own. Care staff that we spoke to also told us this. Of the three care staff that we spoke with, all told us that they shadowed other care staff for “a few” weeks before being allowed to provide care on their own.

The provider had not undertaken any competency checks on care staff to ascertain that they were competent in the safe moving and handling of people. However, all care staff that we spoke with told us that either the registered manager, the deputy care manager, or a staff member with a “train the trainer” qualification showed them how to use the equipment at people homes safely.

Care staff had access to a wide range of training courses, but the provider informed us that they allowed staff to choose what courses they wished to take. This did not assure us that care staff were appropriately trained to meet the needs of the people using the service.

The Provider assessed and managed the risk of infection and controlled the risk of it spreading.
When relevant, the provider shared concerns with the appropriate agencies.

Processes were in place to ensure people were protected from the risk of infection. Most staff had received additional training in the subject of infection prevention and control.
All staff that we spoke to told us what action they needed to take to keep people safe from the risk of infection. People and their relatives consistently told us that staff followed good practise.

The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They involved people in planning, including when changes happened.

We saw that 56.25% of care staff at the service had undertaken medication training, and others were in the process of undertaking this. Most staff had undertaken medication competencies and had been assessed competent by the provider to support people with their medications .
Five people told us that care staff supported them with their medications. Of these five people and/or their relatives, four told us that they had no concerns around staff supporting them with their medications. One person told us, “They’re quite strict about me medication – I can rely on them 100 %.”