Archived: The White 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. At our last assessment we rated this key question inadequate. At this assessment the rating has remained 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 people’s safe care and treatment, the ways people’s medicines were managed safely, people not being protected the risk of abuse and neglect, safe staffing, the unsafe environment and people being unlawfully restricted.

This service scored 25 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

At the previous inspection we found accidents and incidents of distress were not always recorded and where they were there was a lack of detail. There was a lack of consideration around whether the deployment of staff could have contributed to the high number of unwitnessed falls during the day and at night. We found this concern still remained.

There was an inconsistent approach by staff on the recording of incidents. The manager told us staff had the option to hand write them or enter them onto their electronic care planning system. However, we noted that the majority of the incidents were handwritten and were completed by the manager who had not always witnessed firsthand what had occurred. The incident forms lacked any detail on what the incident was, at times no resident name was recorded and there was a lack of evidence of any learning from the incident. This meant there was a delay in putting in place strategies or preventative measures to reduce further risks. There was also no evidence that debriefs were taking place to understand and learn from incidents.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

There had been no people admitted to the service since the last inspection. However, we found there was a lack of pre-assessments taking place where people were returning to the home after being discharged from hospital. This meant the provider could not be assured they were still able to meet their needs and provide safe care. We were told by the manager that 2 people had recently had a period of time in hospital, however their care plans had not been updated to reflect this and there was no information or risk assessments in relation to their declining health conditions. This meant there were no checks to ensure the care and support that service were able to provide remained appropriate or safe.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not 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 share concerns quickly and appropriately.

At the previous inspection we found safeguarding incidents were not investigated appropriately or always reported to the local authority. We found on this inspection this had not improved. There were people who told us they did not always feel safe around other residents with one person telling us, “I’m scared of (person) as she has punched me- but I don’t fight back, what’s the point?” Two people told us they report to staff and the manager their concerns about other people but said they did not feel listened to. One visiting professional fed back, “This is not a safe place at all for their patients (people).”

We saw from incident reports there were incidents of unexplained bruising and injuries to people who were unable to verbally communicate how this happened to their cognitive decline. Leaders had not undertaken a detailed investigation to determined how this occurred. These had also not always been reported to the local authority safeguarding team. Another incident form stated 1 person had thrown a hot drink on another person, yet this had not been raised as a safeguarding incident or investigated. This lack of recognition of what constitutes alleged abuse meant that people were being placed at risk of further abuse. When we discussed recent safeguarding concerns with the manager, that had been raised by external professionals, the manager told us they had not investigated them and that, “I am not concerned by it.”

The provider did not consistently adhere to the principles of the Mental Capacity Act. As a result, some people were subjected to restrictions without the appropriate legal authority. We found that people’s movements were limited using bed rails and a locked front door, and there was not always authorisation in place for these restrictions.

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

We undertook the inspection to get assurances that people at risk of pressure sores developing were being supported safely. We found there were a lack of skin integrity risk assessments in place for people. Where people were being repositioned, there was a lack of guidance on how frequently this needed to be done. We saw from the records staff were not consistent with how frequently they were repositioning. This meant people were exposed to a significant risk of developing pressure related or their skin deteriorating, leaving people in severe pain or requiring hospital treatment. The manager also lacked an understanding of when people required to be repositioned.

Other areas of risk for people were managed poorly including ensuring people were sufficiently hydrated. We saw from the monthly fluid charts for all people, nobody had averaged more than 620mls of drink a day. This is despite NHS guidance stating that people should be encouraged to drink 1500-2000 mls per day. This placed people at significant risk of dehydration and health complications.

The care plans we reviewed lacked assessments and guidance relating to risk associated with people’s care including for diabetes, epilepsy, heart conditions, mental health conditions, constipation, falls and distressed behaviours. Staff we spoke with did not always have knowledge around people’s risks. One member of staff had completed their induction and was actively providing care to people. However, when asked who had the most complex care needs and highest risks they told us, “I have no idea, I couldn’t tell you”. Not understanding people’s risks can lead to serious harm and compromised well-being for the people they are supporting.

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.

The provider did not ensure the home environment was safe or well maintained. People fed back to us that they did not have access to hot water in their ensuite bathrooms. We found the water in the taps in 5 people’s rooms did not have hot water and in 3 of these rooms the water pressure was just a trickle. In 2 people’s bathrooms the sensor lights either flickered or turned off very quickly when you entered the bathroom, which meant people with limited mobility were placed at higher risk of becoming disorientated and falling. In 1 person’s room the radiator cover was not secured which was a risk if the person leaned on this. We found 1 unlocked empty room (which was accessible to people) was being used to store equipment, had a call bell hanging down which was a ligature risk. The emergency grab folder which the fire service may need to rely upon contained incorrect information about the people that lived there. There were people that no longer lived there that were showing on the residents list and incorrect information on the people’s room numbers. There were also out of date items in the grab bag including plasters and gloves. This meant the effectiveness of the items were reduced. Prescribed topical creams were not stored safely and were placed in people’s unlocked cabinets or the shelves in their ensuite bathrooms.

Staff were required to update records for any care being delivered on handheld devices. However, 4 care staff were having to share 2 devices. One member of staff told us that any updates to care being provided, “I have to report to senior lead.” This meant there were a delay in recording care that had been delivered.

However, we did find that some maintenance areas of the service had improved since the last inspection. Regular Health and Safety checks were undertaken by the maintenance team for moving and handling equipment.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Whilst we observed there were sufficient numbers of staff on the day of the inspection, they were not effectively trained or supervised. There were 4 care staff on duty, however, 1 told us they had only recently started at the service and told us they did not know people’s needs. The member of staff also did not appear on the training matrix, so it was unclear what training they had received. On the majority of day and night shifts the service used regular agency staff however, according to their agency profiles, none of the staff had received dementia training. This was particularly concerning given the majority of people living at the service were living with dementia. One member of staff told us, “Think they (staff) need a lot of guidance. They are asking a lot of questions about what how to deliver personal care. (Staff) Need to use more initiative.”

The manager told us that no people were on a modified diet, however on review of care plans at least 2 people required to have their meals modified. Despite this, the chef was unable to explain what consistencies were needed for people aside from ‘liquidising’ 1 person’s meal (their care plan stated they only required the food to be soft). They told us they had not received any training around how to ensure the correct consistency of food, and we confirmed this from the training matrix.

Supervisions were not effective in driving improvements. We saw from 1 supervision the manager had undertaken with a member of housekeeping staff, that Control of Substances Hazardous to Health (COSHH) training was required for them. However, when we checked the training matrix this had not been provided. We saw from 2 other supervisions that updated moving and handling training had been recommended for staff however, according to the training matrix, this had not been undertaken. Where poor performance was identified and discussed with staff, the manager told us they did not always record this.

One visiting professional told us they had provided training in skin integrity however they said staff were still not providing appropriate care around skin integrity, therefore placing people at far greater risk of their skin deteriorating as it was not being managed safely.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading.

People were at placed at risk as the provider had failed to ensure good infection, prevention, control practices. We found there was a strong smell of urine in several areas of the home, particularly near or in people’s bedrooms. The provider told us they also identified this on the day of the inspection. There were people’s mattresses that had a strong odour of urine, indicating that cleaning practices and bedding management were not consistently effective. During the inspection, for several hours we observed 1 person that had a large faces stain on the back of their clothing and had been sitting in various chairs around the service. The leaders or staff had not managed this to ensure the person and other were protected from the risk of infection. Another person had been incontinent and was left wet in their clothing for over 25 minutes despite staff being aware. We also noted on an incident form that this person had sustained a skin burn from urine the previous month, indicating they had been left in wet clothing for a significant period of time. Infection control audits were taking place, but they were not effective in identifying and addressing all of the concerns.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Whilst there were some people that received their medicine as prescribed, there were elements to the management of medicines that were unsafe. Where people required prescribed creams to be applied, there were multiple gaps on the cream charts. Where people required a patch applied to their skin to aid with pain relief, staff were not always ensuring that this was still in place. We saw examples of not signing to say a person had received their medicines. When we did the medicine counts, they were not always correct meaning some people had not received their medicine. When we raised this, we found the leaders had retrospectively signed the medicine record without first checking if the person had missed a dose. Where people required ‘as and when’ medicine to relieve their agitation and constipation, there was a lack of guidance for staff on when they needed to give this.