Westbourne 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 newly registered service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to managing medicines, premises and equipment, managing risks posed to people, staffing and infection, prevention and control.

This service scored 38 (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. Whilst systems were in place to monitor accidents and incidents, these were not robust. We found several incidents which had not been reviewed by the management team, or lessons learned following incidents. The management team monitored the number of accident and incidents through a monthly audit, which included reviewing people's care records to look at themes and trends, however we found an incident relating to a fall which was not captured in this record. Staff did not always complete incident forms when people became distressed. When forms were filled in, they often lacked clear details about how the person presented and how staff helped them to calm.

The provider did not always manage or monitor people’s safety. They did not always make sure there was continuity of care. Records evidenced staff worked with social workers to form assessments of people's needs prior to them living at the service. Staff worked with a range of external professionals to meet people's physical and mental health needs; however improvements were required to records to ensure information shared between services contained enough information.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. 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. There were clear systems in place to enable staff to whistle-blow on poor practice. A staff member said, “The managers are great. I can talk to them and report things. I always double check and report everything.” There were no safeguarding concerns at the time of our assessment. Staff were trained on how to safeguard people and told us they felt comfortable to raise concerns and were confident action would be taken. People told us they felt safe, and staff told us people were safe living at the service. One person told us, “I have never had any issues while staying at the home the staff make me feel safe."

The provider did not work well with people to understand and manage risks. Where a person had a diagnosis of epilepsy, staff monitored them at periods, however there was a lack of continuous monitoring equipment in place, to ensure staff could be alerted in the event of a seizure. It had not been explored with this person if they wished to have continuous monitoring in place to maintain their safety. We found a lack of falls risk assessments and care plans for a person who had a history of falls. There was little information in kitchen areas about modified diets or best practice guidance, even though people’s care records included details of nutritional and choking risks. This meant staff relied on their own knowledge to prepare food safely, and while they told us they understood people’s needs, the lack of written guidance increased the risk of mistakes.There was a lack of robust care plans where people had incidents of distress and poor mental health, some information was available to staff, however records lacked detail about people's triggers, presentations and what worked well for them during these incidents. We found a lack of records relating to a person's bowel movements, which required monitoring. We also found a lack of information relating to the use of a wheelchair, this information was not included in a person's care plan or risk assessment.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. We found hazardous items stored in an unlocked cabinet. We found a kitchen which was out of use and currently undergoing building works to be open, this area contained exposed pipework and electrical wiring. The provider had recently undertaken works to ensure the building was compliant with fire safety measures, people had personal evacuation plans in place and staff undertook fire evacuation exercises. However, we found 2 fire doors to be propped open during our tour of the building. Outside garden areas were overgrown and could not be safely used. Some radiator covers were not in place, and no windows to upper floors contained window restrictors. This placed people at risk of harm. Following our assessment the provider assured us these works had been undertaken. There was a lack of appropriate risk assessments undertaken to manage the risk of legionnaires disease and measures were not always undertaken to manage this risk, such as flushing of unused outlets and descaling of shower heads. We spoke with the maintenance team on the day of our assessment and were assured these would be undertaken moving forward.

The provider did not make sure there were enough qualified, skilled and experienced staff. We could not be assured people were supported by enough staff. At times in the afternoon and at night, only one member of staff supported ten people. The provider did not use a dependency tool to calculate how many staff hours were needed. Although many people were independent, some were at risk of falls, seizures, or distress, and others needed help with personal care. The building was spread over several floors and rooms, which increased the challenge of lone working. This meant staff oversight was limited, and some staff told us they felt there were not always enough staff. A staff member said, “Sometimes there isn’t enough staff, if I am carrying out personal care for a person, it can make me anxious knowing there are no other staff around.” A relative said, “I do have concerns about how long it takes staff to respond to [Name] in the event of a fall, there isn’t a call button in their room.” Staff were recruited safely, and all appropriate pre-employment checks were in place. Staff were trained in a range of subjects to enable them to carry out their roles effectively.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading. Whilst some areas of the building were found to be clean, and personal protective equipment (PPE) was available for staff, other areas were found to be visibly dirty. For example, we found some soiled flooring and soiled chairs. Out-of-date hand gels were in use, which posed a risk to effective infection prevention and control. Some areas of exposed wood could not be cleaned properly, increasing the risk of infection spread. Although some bathrooms had been refurbished, others remained in poor condition with limescale, mould and soiled flooring, which created hygiene risks.

Medicines were not always safely managed. Medicines for services users were kept in separate locked cabinets behind a locked door. Temperatures of these areas were sometimes documented to ensure medicines were being kept in the correct conditions. However, there were significant gaps in these records so we could not be assured they had always been kept at appropriate temperatures.

On the day of inspection there were no prescribed medicines that required refrigeration. However, there was no separate medicine fridge available in the service to store medicines requiring refrigeration if need be. These medicines would be kept in a separate cabinet within the main kitchen fridge where food products were stored.

Controlled drugs, which have the potential to be abused, did not have regular stock checks or audits completed. Stocks checks were only completed when doses were administered, e.g. every 3 days. They were not managed in accordance with national regulations. Similarly, stock balances were not documented on people’s medication administration records (MARs) so it was unclear if stock levels were correct. Some creams and ‘as and when required’ (PRN) medicines were not available when stocks were checked.

People prescribed ‘as required’ (PRN) medicines did not always have protocols in place to ensure staff would know when to give these appropriately. Protocols that were in place lacked detailed, person-centred information. Some had wrong information on them which could lead to incorrect doses being given. When people were given PRN medcines documentation was not always clear on the PRN outcomes sheet and was sometimes added onto the bottom of the MAR chart. It was not clear which medicine this information referred to.

When a service user was prescribed a variable dose, e.g: 1 to 2 tablets, staff did not always document what dose they had administered. This was not picked up on monthly medicines audits.

For people that self-administered their own medicines, documentation on their MAR charts did not give a true representation of when doses had been missed. Separate self-administration checklists were in place to ensure people were taking their medicines safely, but it was identified that on numerous occasions they had not taken their medicines, and no further action was noted. These missed doses were not shown on the MAR chart, so conflicting documentation was evident.