West Wood 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 inadequate. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.
The service was previously in breach of the legal regulation relating to safe care and treatment and staffing. On this inspection we found they were no longer in breach of these regulations.

This service scored 69 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

We found the service acted upon safety alerts received and shared between the team. Data was analysed to improve outcomes for people around falls and weight analysis and call bell response times. Accidents and incidents were reported promptly, and investigations were conducted appropriately to identify root causes and learn from areas of improvement. These instances were shared with the workforce and lessons learnt were embedded.

Staff assured us on the process they followed in escalating safety concerns. People told us they felt able to raise safety concerns. A person told us “I normally go to the nursing station. Normally I see [staff members] I feel confident going to them to tell them. They are lovely.”

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. The service ensured pre-admission assessments were conducted before people moved into the service. The provider carried out post-admission audits to ensure all admissions were safe, and all required checks were completed.
A person told us, “I came to see the home and had a look around and checked the facilities and where I would be sleeping. I thought why go home?” Another person said, ““[Relatives] came and had a look around the home and then I came and had a look around the home as I was unable to cope at home by myself anymore.”
People and healthcare professionals told us referrals were submitted in a timely manner. A healthcare professional told us, “On occasions I have recommended referring to [healthcare professional.] This has been acted on.”

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. The provider shared concerns quickly and appropriately.
The provider ensured people were protected from avoidable harm. Safeguarding referrals were raised where required and additional actions were taken to protect people from increased risk of harm. People felt safe and most relatives felt people were safe. A relative told us, “Person is absolutely safe as there’s always staff around.”
Staff informed us they had received safeguarding training, how they monitored people for signs of abuse and how to report them. A staff member told us, “I monitor for signs such as unexplained injuries, sudden behavioural changes, poor hygiene, fearfulness, neglect, or emotional distress. If I notice anything concerning, I would report it immediately to the deputy or manager and follow according to policy.”

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. We found a person who had an ongoing pressure ulcer and was at high risk of their skin breaking down further had not been supported to reposition as frequently as advised by supporting healthcare professionals. When we made the provider aware of this, they advised the person often refused being repositioned. Their care plan made no reference to this and there was no evidence of involvement with other healthcare professionals to manage risk. The provider identified this was a shortfall, amended the care plan, implemented a risk assessment, and involved healthcare professionals regarding the risks identified and increased equipment in place to support them.

Other care plans we reviewed identified risks appropriately and were clear for staff to follow on how to mitigate and manage the risk posed. People told us how they were supported by staff, 1 person told us, “They think of the little things. Stop you from scalding yourself. They check on me a lot at night.” Two relatives were concerned about people and their risk of falls. We informed the provider of this, and they told us they were going to speak to families regarding people’s falls and actions taken.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The environment was spacious and had appropriate risk assessments in place. Equipment was well-maintained and serviced. The provider had a clear fire procedure in place, updated personal emergency evacuation plans (PEEPS), ensured they were readily available and all staff had undertaken regular fire drills.

The provider conducted daily checks to ensure the environment was maintained and staff assured us on the checks they carried out on equipment prior to using it. People told us how they were happy with the environment and the maintenance of the building. A person told us, “Maintenance make sure pictures are put up safely. The alarms go off frequently.” Another said, “Oh yes, I love my room, I can look out and see the train and the golf course. It’s lovely and cool on this side.”

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 received mixed feedback from people around the staffing levels. Some comments we received were, “The staff have to do more than just their job,” and “It varies, I would say they have a shortage I would have thought. It varies throughout. I think the night staff is better than days. They seem more visible and responsive.” However, another person told us “Oh yes, there’s enough. You don't have to wait for long.” And, a relative told us “Last time I went they were well staffed.”

We raised this with the provider, and they showed us the dependency tool to assess the levels of staffing required to their rota. The provider analysed call bell times, shared these with us and had seen an improvement every month. They had plans in place to increase staffing as occupancy increased and had recently implemented another staff member on shift due to occupancy. They were going to speak with people and their relatives to discuss the staffing issues.

The provider had a recruitment policy in place and staff had safe recruitment checks conducted on them prior to starting in the service. This included Disclosure Barring Service (DBS) checks conducted to ensure staff were suitable to work in the environment. Staff had risk assessments in place and received regular training.

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. We observed the environment to be clean and tidy. On 1 site visit, we identified 2 areas of slight malodours; however, these were tended to promptly. The service conducted regular infection prevention control audits of the environment to ensure cleaning standards were maintained.

The provider held a register to monitor the amount of infections people had developed in or externally from the service. However, it was not clear enough to identify if there were potential outbreak case as it just recorded the number of infections for that month. We brought this to the provider’s attention, and they reviewed the cases to be assured they did not constitute to an outbreak and implemented a lesson learnt to record the date the infection was identified.

People and their relatives were mostly happy with the cleanliness of the service. There was a concern of the odd malodour, however these were dealt with promptly. A person told us, “It's kept to a very high standard, I have always kept my home nice, and this is the equivalent.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found staff were not assessing a person that was unable to vocalise if they were in pain. A staff member told us, “We know them and when they are in pain.” However, they had no evidence of that pain being assessed or monitored to ensure it was improving. The provider acknowledged this and implemented a supervision with staff on the importance of clinical assessment tools and how to use them.

People received the medicines accurately and safely. People that were on time sensitive medicines received them correctly. People living in the service that managed their own medicines had risk assessments in place and told us staff checked their stock regularly. We reviewed the controlled drugs process, and it was clear and accurate. Medicines were routinely audited and staff had a clear policy in place to follow. Staff received medicine training and were assessed regularly to ensure they were competent in handling medicines.

A person told us, “I manage my own medication, and they come in and check it regularly.”