Whitehaven 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 requires improvement.

At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

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.

Records showed staff reported incidents which the manager reviewed and put measures in place to reduce the risk of a similar incident occurring.

Relatives said they were informed of incidents. One relative said a risk assessment had been completed after their relative had fallen. The relative said, “Actions were taken to place a bedside alarm warning mat in and put [person’s name] waking frame within reach.”

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.

Records showed information about people was available and shared with health care services when needed. For example, a ‘red bag hospital transfer form’ was used which included key information about people’s health conditions.

The registered manager explained they shared information with other providers when people moved from the service to different services to help new providers understand the person’s care needs.

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 registered manager raised safeguarding incidents with the local authority and raised notifications with CQC where appropriate.

Staff had received safeguarding training and were able to explain the steps they would take if they identified any safeguarding issues.

One relative told us they had raised a safety concern, which was addressed effectively.

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. We found that DoLS notifications had been submitted appropriately,and the manager used a DoLS matrix to help them keep on track of DoLS applications. Staff had received training relevant to DoLS.

However, there were some safeguarding incidents that had not been notified to CQC. The registered manager explained that these incidents had been raised by health professionals, and they believed that CQC would have been informed by those parties. The registered manager confirmed they will ensure all safeguarding incidents are notified to CQC in the future.

The provider did not always work with people to understand and manage most risks by thinking holistically.

We identified some gaps in medicines risk assessments and Personal Emergency Evacuation Plans (PEEPs). While care plans were in place to support staff, additional detail was needed to fully assess risks to other people. We did not find any evidence that these shortfalls had caused harm to people and staff could explain the action they would take to mitigate risks for people. We discussed this with the registered manager and saw evidence the missing information was addressed during the inspection.

However, most risks associated with people’s care were identified and plans were in place to mitigate future risks. We observed care being delivered in line with people’s care plans.

People’s needs were assessed and kept under review. Care plans were updated as people’s needs changed.

Relatives confirmed they were involved in people’s care plans, and health and social care professionals also contributed where appropriate.

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 provider made sure regular health and safety checks took place to maintain a safe environment. These included routine fire safety inspections and monitoring water temperatures.

The environment appeared safe and well maintained.

Staff received fire awareness training and took part in fire evacuation drills to ensure they could respond effectively in an emergency.

During our visit, we noted that the layout of the communal lounges and the noise from two televisions placed close together could affect people living with dementia and potentially lead to distress. The registered manager told us they would review this and consider changes to create a quieter, calmer environment.

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.Staff had received training to enable them to support people safely.The registered manager said they used a ‘Dependency tool’ to ensure the service had enough staff to safely support people.Most people said there were enough staff and that staff were trained.One relative said, “Every-time I go there all the staff are around. [Person] can use their call bell, and staff are there in 30 seconds”

One relative told us they felt some agency staff lacked knowledge and skills. The registered manager explained regular agency staff are used where possible, and all agency staff received an induction to the service. The manager also checked agency staff had the necessary training to ensure they were appropriately skilled.

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. Staff had received infection control training and systems were in place to check and reduce the risk of the spread of infection. For example, cleaning schedules were used to ensure the service was effectively cleaned. There appeared to be sufficient Personal Protective Equipment (PPE) and hand washing facilities available. The service was clean and free from odour.

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

In some cases, care plans were lacking in the required detail to support the safe use of some medicines. For example, 2 people were prescribed high risk medicines associated with a risk of bleeding and bruising. There was no risk assessment to support staff to manage this scenario. However, staff were able to tell us how they would manage this situation, and the registered manager had completed the risk assessments during the inspection. Prescribed topical creams were not stored securely and this had not been risk assessed. This meant people may have been able to access these prescribed medicines which put them at risk of harm. The provider took steps to ensure people’s creams were safely stored during our onsite visit.

However, there had been an improvement since the last inspection. Care plans contained person-centred information on how residents liked to take their medicines. Protocols were in place to support the use of “when required” medicines, such as painkillers and laxatives. Medicines, including controlled drugs were stored appropriately according to the services policies. Policies and procedures were in place relating to medicines and we observed staff following these during our visit. A system of medicines audits was in place at the home, and we saw examples of how this audit system had been used to improve practice related to medicines. Staff completed mandatory medicines management training and annual assessments were completed to ensure they remained competent.