244 Wootton Road

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 inspection we rated this key question Good. At this inspection 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 regulations in relation to safeguarding service users from abuse and improper treatment, the way people’s medicines were managed safely.

This service scored 44 (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 culture of safety. Staff did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The service currently uses both a paper based and digital system to record and monitor accidents and incidents. We found that staff completed paper forms to record accidents and incidents, along with health observations such as bruises. A digital incident log was in place to monitor accident and incidents, however not all accidents/incidents which had been recorded by staff were included on the incident log. Therefore, not all incidents had been reviewed to identify opportunities for learning. This meant that opportunities were missed to mitigate future risks and to improve the care people received.

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.

We found that not all people’s care plans were always on the premises, on the first visit 1 person’s mental capacity assessments folder was at the other service and on the second visit 1 person’s full care plan was at the other service. However, staff had a good understanding of people’s care and support needs.

The service had systems in place to support new people moving into the home. This included the service spending time with people in their previous home which they were familiar with.

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, abuse, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

We found that incidents of concern were not consistently monitored or identified using the systems in place. This meant that safeguarding concerns had not always been investigated or reported to the Local Authority.

Staff received training around safeguarding, however, some staff spoken with were unsure of safeguarding procedures.

Relatives told us they felt their family member was safe, but governance failures placed people at risk of harm.

The provider did not always work well with people to understand and manage risks.

We found that the care plans on the premises included risk assessments which had not been regularly reviewed. One person’s care plan when viewed on-site did not include a Positive Behaviour Support plan (PBS), this was in place and later provided as part of the inspection. Another person’s PBS plan had not been reviewed since 2022 and included out of date information which could have placed them at risk. However, staff had a good understanding of people’s needs and people were encouraged with positive risk taking.

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.

The service had systems in place to review the safety of the environment; however, we found that these were not always effective in identifying areas of concern, or where they had action had not always been taken in a timely way to address these.

We found paperwork on the premises relating to fire safety such as the evacuation plan and other paperwork included information regarding the other home as well which could be confusing. The fire risk assessment on the premises was not the up-to-date version.

Staff had recorded hot water outlet temperatures, however, a number of these were below recommended temperatures. This had not been identified and increased the risk of harmful bacteria growth.

People had detailed Personal Emergency Evacuation Plans (PEEPs) in place.

The provider did not always make sure that staff were qualified, skilled and experienced.

People received either 1:1 or 2:1 support and it was found that staffing levels were well planned and maintained. Staff told us that they felt they had enough time to support people, but some staff did not always feel they had enough time to read care plans or complete documentation. One staff member told us, “Most of the time there is little time to read everything thoroughly.”

Staff supported people with their finances; however, they had not received training relating to financial safety or management. Staff had received other appropriate training, which was needed to support people, such as positive behaviour support (PBS).

We had concerns that staff had only received competency checks for medication.

The service followed a robust recruitment process.

The provider did not always assess or manage the risk of infection.

Systems were in place to monitor Infection Prevention and Control (IPC); however, they were not robust and did not efficiently identify risks. Where risks had been identified, timely action had not been taken to rectify concerns. IPC audits contained many of the same concerns over 3 months.

The environment was observed to be homely and clean. Relatives told us, “It is always clean enough when I have visited”.

Staff had received IPC training, food hygiene and Control of Substances Hazardous to Health (COSHH) training. Staff had access to appropriate Personal Protective Equipment (PPE).

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

During the first visit we found that when required medication (PRN) charts were not always in place and some included PRN paperwork for medication that was not in the home. This was given as feedback to the manager at the time; we found the same concerns on our second visit.

People were prescribed topical creams, but there were no topical application charts in place to record where these should be applied and if these had been applied.

One person’s care plan included paperwork from health professionals which included at least 1 medication allergy; this was not recorded on the MAR chart and had not been identified by the service.