Enhanced Elderly Care Service - Wardley Gate Care Centre

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.

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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learned to continually identify and embed good practice. Systems were in place to share outcomes and improve practice. However, these were not always effective in identifying wider risks or all concerns at an early stage, as some issues identified during the assessment had not been recognised through existing processes.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. Care records did not always support continuity of care. We found examples where records contained conflicting information and did not always provide clear guidance for staff about how people's needs should be met. This meant staff could not always rely on records to consistently support safe and coordinated care. One relative told us, “Apart from the initial questionnaire and the health care plan being completed before transferring to the home I cannot recall completing any other care plan for my relative.”

People were protected from abuse and avoidable harm. Staff understood safeguarding procedures and knew how to recognise and report concerns. Issues were escalated appropriately and managed with relevant agencies, providing assurance that concerns were taken seriously and acted upon. One staff member told us, “I would not hesitate to inform the appropriate people if I had any concerns.”

People were involved in decisions about their care and how risks were managed. Risk assessments reflected people’s preferences and promoted independence while maintaining safety. Staff worked with people and those important to them to review and update plans, supporting positive risk taking in a structured way. One relative told us, “The staff listened to all the information I had for [Person] including their personal preferences and routines.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment and facilities supported the delivery of safe care. The environment was generally clean and maintained, with routine safety checks in place. However, we identified risks including unsecured areas, unsafe storage and environmental hazards. The provider took immediate action, but oversight systems were not consistently effective in identifying and addressing risks. One person told us, “The garden areas could be improved.”

Although staffing levels were planned using a dependency-based approach, people did not always receive timely support and positive engagement. Observations during the assessment indicated that the quality and consistency of support people received was not always reflective of the staffing arrangements in place.Leaders recognised there were staffing pressures and were taking steps to address these, although this was not yet consistently effective at the time of the assessment. Staff were trained and had access to supervision and support, although this did not always translate into sufficient staffing deployment across the service. One staff member told us, “There isn’t enough staff on any floor”.

The provider did not always assess and manage the risk of infection effectively. There were systems in place to support infection prevention and control (IPC), including cleaning schedules and audits, and the service was generally clean, but we identified issues such as poor food labelling and inconsistent waste management and waste storage. This meant infection control practices were not always applied consistently. One person told us, “It could be cleaner. The odour is sometimes unbearable.” These issues were not evident across all areas of the service but demonstrated inconsistency in how IPC practices were applied.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Systems supported the safe ordering, storage, administration and review of medicines, including audits and staff competency checks. Staff followed processes for administering medicines safely, and governance systems provided oversight. One person said, “I don’t have problems taking my medication because staff stay and make sure I’ve taken them with no problem.”