Wentworth Court Care Home

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 people’s safe care and treatment at the service.

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 as, at the time of the assessment, there was not an effective system in place to evidence themes had been analysed and lessons had been learnt to continually identify and embed good practice.

Whilst the provider had some processes to identify learning, these were not always effective, meaning there were missed opportunities to drive improvements following untoward events. For example, systems had not been established or implemented to effectively audit and monitor service user falls. Quantitative data for people’s falls had been completed and was up to date. However, this was a simple tally chart and there was not an effective or current record to demonstrate that analysis had been completed to monitor and mitigate the ongoing risk of falls for people.

Staff told us they were encouraged and supported to raise concerns about risks to safety, and they felt confident action would be taken to keep everyone safe. One staff member said, “I feel I can go to the registered manger or general manager with any problems. If I had a concern I would feel confident to raise.”

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.

People’s needs were assessed before they moved to the service, helping staff understand people’s needs and life history. The service established relationships with a range of health care professionals, who told us that staff provided them with the necessary information about people when it was requested.

Staff worked together to plan and deliver care that maintained people’s safety. Handover meetings between night and day staff included information about health needs, well-being and changes in people’s condition. Nurses demonstrated awareness of risks, including how to escalate concerns and when to involve external professionals. A healthcare professional told us, “Urgent requests are communicated via the correct channels and allow for swift review and action from [professionals].”

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. Despite this we identified concerns in relation to the providers oversight of the Deprivation of Liberty Safeguards (DoLS).

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. The provider did not have a clear process to record DoLS applications and conditions, which meant they were not routinely reviewed. Whilst we found no evidence to suggest that people were being deprived of their liberty unlawfully, the absence of a clear process meant that we were not assured people were receiving adjustments as and when their needs changed. This placed people at an increased risk of being deprived of their liberty unlawfully. The registered manager told us they were strengthening their systems to ensure they maintained effective oversight of the process on an ongoing basis.

Staff completed safeguarding training and knew how to recognise and report safeguarding concerns. Staff told us they would be comfortable reporting poor practice to management. Policies and procedures supported the safeguarding process and provided guidance and information for staff. The registered manager reported safeguarding concerns appropriately to the local authority and CQC.

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, supportive and enabled people to do the things that mattered to them.

Some care plans lacked key information regarding the management of risk. For example, we reviewed the records for a person with a specific health condition. Whist there was information relating to this recorded in the medical illnesses section of the care plan, there was no further information recorded in other relevant sections of their care plan or risk assessments, and no protocol in place relating to the management of their condition. This meant we were not assured that staff would take a consistent approach to protect the person from harm in the event of acute ill health relating to the condition.

Some people expressed their emotions and anxieties in a specific physical or verbal manner. We did not always see a clear record to demonstrate how staff had responded in accordance with best practice when people had been physically aggressive and experienced behaviours of distress. Whilst we saw no evidence of negative impact, the absence of a clear record meant that we could not be assured people were consistently supported by staff using appropriate strategies and minimising the need for restrictive interventions. We discussed this with the registered manager who was looking to strengthen the process by liaising with external professionals for support.

Each person had a personalised evacuation plan with clear guidance for staff and emergency services on the support they would need to evacuate the building safely in the event of a fire. This information was easily accessible.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.
Whilst the environment was clean, warm and welcoming, we saw that some hazards in the environment had not been managed and mitigated in a timely manner. For example, we raised concerns in relation to the safety of a section of the garden and the accessibility of hot breakfast utensils at an upstairs serving station. The provider took immediate action in response to our feedback and resolved both issues effectively and efficiently. However, they had not, through their own systems, identified the urgency of the work needed to ensure the environment remained safe and suitably adapted for the needs of people who lived at the home.

There were effective fire safety procedures in place. The signage, the decoration and other adaptations to the premises helped to meet people’s needs and keep them safe.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We used the Short Observational Framework for Inspection (SOFI). SOFI to observe the care and help us understand the experience of people who could not talk with us. We saw that although staff were exceptionally busy, they were skilled and knowledgeable about people’s needs. A dependency tool had been used routinely to calculate the needs of people and ensure there were enough staff available to meet people’s needs. A relative told us, “There is absolutely enough staff and there are always the same staff. It needs to be well staffed to meet their needs of the [people] and the staff.” Another relative said, “Yes, I do. they seem to have a lot of staff, if I have a question I can always find someone.”

Staff had completed training relevant for their role and had received supervisions. Rosters showed there was continuity of care for people. One professional said, “Continuity of care is excellent, which benefits both the residents and their families and supports improved clinical outcomes.”

Staff were recruited safely to the service. This included requesting and receiving references from previous employers, right-to-work documentation and Disclosure and Barring Service (DBS) checks. DBS checks are carried out to confirm whether prospective new staff had a criminal record or were barred from working with people at the time.

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.

The home was clean and hygienic. Personal protective equipment (PPE) and required cleaning materials needed were available. Cleaning schedules were in place and had been followed by care and maintenance staff.

There was an up-to-date infection control policy and procedure in place, and staff had received training to support with minimising the risk of infection. Information about safe infection prevention was easily accessible. Relatives told us that the home was clean and that staff wore PPE as required.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.
Improvements were needed to the way medicines were managed in the home.

We observed that medicines were given to people in a person-centred and caring way. Staff took account of people’s preferences on how they liked to take their medicines. We heard positive feedback from people’s relatives about their experiences of living in the home. Staff worked closely with the GP practice to resolve medicines issues in a timely manner and to ensure people received medicines reviews.

During our visit we saw that some Medicines Administration Records (MARs) contained gaps. Staff could not explain these gaps or account for what had happened with medicines administration on these occasions. This meant we could not be assured that these medicines had been administered as prescribed. Some of the medicines associated with these records were “time-critical” meaning that failing to give them at the prescribed time would be likely to have an impact on a person’s health.

Care plans contained information about medicines from specialist clinical teams, such as the diabetes teams. We saw that, records indicated, staff were not always following the instructions provided by these specialists in relation to medicines and medicines were not administered according to their instruction.

In some cases, care plans and MARs were lacking detail to support the safe use of medicines. For example, information to support staff with the use of “when required” (PRN) medicines, such as painkillers and laxatives, was missing in some cases. Staff told us this was because they did not have time to complete these records. This meant we could not be assured that PRN medicines were always being administered as prescribed.

Medicines risks were not always considered in care plans. For people prescribed high risk medicines associated with a risk of bleeding and bruising, there was no risk assessment in place to support staff to manage this scenario. However, staff were able to tell us how they would manage this situation and began to undertake these risk assessments during our visit. Additionally for people prescribed flammable topical creams there were no risk assessments in place. Staff told us these medicines risk assessments were not completed because they did not have the time to do this.

We saw inconsistencies in medicines records. For example, we saw a number of people with allergy status recorded differently in their care plan and on their MAR and staff could not confirm which record was accurate. This meant there was a risk that people could be prescribed or administered medicines they were allergic to, and therefore we could not be assured that medicines were being managed safely.

Topical pain medicines in the form of patches were not managed according to best practice. There was no system in place to ensure that patches remained in place between scheduled changes. We saw incidents where, at the time of removal, patches were no longer in place and staff could not locate them. These patches were controlled drugs (medicines that require additional controls and safeguards according to the law). This meant we could not be assured that people’s pain was being correctly managed in the home or that controlled medicines were being managed safely. Staff told us that some people affected would have been unable to communicate they were experiencing pain, increasing the risk of unmet pain management needs.

Topical creams were applied by carers during personal care. Paper charts were in place for staff to record application of these creams and it was also possible to record them on the electronic system. Staff were not clear on where the correct place to document this activity was and, in some cases, records were not being made either on paper or electronically. Therefore, we could not be assured that all topical cream applications were being administered as prescribed.

Medicines were not always stored appropriately and according to the services policies. For example, we saw doors to rooms where medicines were stored were left unlocked and propped open. Therefore, access to medicines was not restricted to authorised staff. In addition, prescribed topical creams were not always stored securely and this had not been risk assessed. This increased the risk of unauthorised access to medicines, including by residents.

Although medicines policies and procedures were in place at the home, staff were not following these. A system of medicines audits was in place at the home; however, staff told us that over the last few months they had not had time to complete these audits. Most staff had completed mandatory medicines management training and had undergone annual competency assessments to ensure they remained competent.