Weston Favell Houses

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 remained Good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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.

The provider had systems and processes in place to record, report, and investigate safety events. There was evidence of accidents and incidents being reported and staff were able to describe the process for recognising and reporting accidents and incidents.

Staff talked positively about the contribution the internal multi-disciplinary team (MDT) were able to have in relation to incidents. Where incidents happened, these were added to the weekly agenda for MDT to discuss any concerns and agree steps to mitigate risk of recurrence.

The provider had developed an internal dashboard to report on accidents and incidents, and although work on this was on-going, this enabled the provider to monitor themes and trends.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. Their records did not always support them to make sure there was continuity of care when people moved between different services.

The provider had systems and process in place to support safe systems, pathways, and transitions. We found work was required to improve some of the guidance and information available for staff and external professionals. For example, we found the emergency hospital admission risk assessment did not provide professionals with sufficient detail to enable a smooth transfer during an emergency.

We also found that personal emergency evacuation plans (PEEPs) did not take into consideration all potential scenarios to provide appropriate guidance to people, staff or external professionals responding to an emergency evacuation of the service. For example, a person’s PEEP did not consider the different evacuation routes that maybe needed depending on the persons location in an emergency.

The provider acknowledged the areas for improvement during our assessment and told us they would review their templates and make changes to incorporate our feedback.

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.

There were safeguarding policies in place. The provider had a designated safeguarding lead and staff were provided with relevant safeguarding training. Staff were able to recognise the signs of abuse and describe the action they would take if they were concerned people were being abused.

We found there was a safeguarding log of concerns and where appropriate, concerns were reported to the police, local authority, and CQC.

People and their relatives told us the service was safe. A person told us, “It’s very safe here, there is always someone to help.” A relative told us, “I do definitely feel [relative] is safe.” Another relative told us, “‘Yes, indeed [relative] is safe, and I am confident that if I had any concerns they would be addressed.” We found there were opportunities for people to speak regularly with the registered manager during ‘catch up with [name of manager] sessions.’

The provider submitted Deprivation of Liberty Safeguards (DoLS) applications and were upholding their obligations to safeguard people who had restrictive practices in place and were unable to consent to their care.

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

The provider used a risk assessment screening tool to capture people’s risks and assess the likelihood and severity of the risks. Based on the screening tool a risk management plan was then implemented.

We found the screening tool, risk management plans, and the evaluation of risks were not always consisted with each other. For example, a person’s falls risk assessment found they were a low risk of falls. However, we found the risk mitigation plan contradicted this assessment and had identified the person was a medium risk of falls.

Although staff and people told us they had been involved in the development and review of risk management plans, more work was required to evidence this in records, to be assured people were always supported to understand and manage risks.

The provider acknowledged there were changes required to their triangulation of risk and told us the improvement they planned to make during the assessment. We were assured by the end of the assessment this work had commenced.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety policies were in place. There was a locally based team responsible for grounds and maintenance. The team were well integrated into the home and had a good relationship with people and teams. One member of the team told us the maintenance team were, “Committed to making sure residents were having a good life,” and “Anything resident related was addressed immediately.” People felt the maintenance team played an active part in their support.

We found the maintenance team completed regular health and safety checks and audits. There were some improvements required to effectively record actions that had been taken in response to the findings of checks and audits. For example, records needed to fully reflect action taken if a thermostatic mixing valve (TMV) temperature was high and an adjustment had been made to the valve to address this. However, we were assured by the Maintenance Manager this learning would be shared with the team and reflected in their daily practice.

We found the staff recruited recently had been recruited safely and in line with the provider’s safer recruitment practices. However, we found some historical recruitment had not always met the standard required. We shared this with the provider who assured us they would take appropriate steps to mitigate the concerns we found and audit all other historic staff files.

A staff member told us it was sometimes difficult to provide the support required in the evenings or at the weekend when managers and members of the MDT were not at work. However, we found there was enough staff deployed at the service to meet people’s needs and on-call support was available. People and relatives told us there was enough staff. A person said the staff were, “All brilliant,” and “There was always someone here for us.” A relative said, “I have no concerns over the number of staff, and they are well trained in acquired brain injury.” Another relative told us, “Yes, I think there is enough staff.” Although there was some agency use to cover vacancies, there was evidence agency workers were inducted to the service.

There were regular supervisions and appraisals, and staff confirmed they regularly met with a manager or service lead for supervision and the registered manager for an annual appraisal. Staff and meeting minutes confirmed team meetings took place on a regular basis.

The provider had a range of mandatory and service specific training. The provider told us at the beginning of the assessment there was work required to improve training compliance, and that a project was in progress to look at aligning the training required at each home. We found there were improvements needed to address training compliance and staff told us during the assessment that they felt there were too many courses for completion.

We were assured by the provider’s action plan to address the improvements needed in relation to training compliance and the proposed changes to the training allocation, which we found would address the concerns raised with us by staff.

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.

There were infection, prevention and control policies in place and we found regular infection control audits were completed by managers. Where audits had identified concerns, actions and timeframes were agreed and the status of the actions monitored for completion. For example, where the audit had identified a carpet was ripped and had created an infection control risk, quotes had been obtained, and the provider had arranged replacements to ensure the action was completed in a timely manner.

The service was clean and tidy. We found a senior team member was checking cleaning standards by completing a weekly audit and addressing any concerns.

There was adequate supply of PPE equipment and staff were able to demonstrate the actions they would take in the event of an outbreak.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Staff involved people in planning, including when changes happened.

The provider had a medicines policy. Medicines were managed safely, and staff had received adequate training and medicines competencies were completed. We found medicines were stored safely and securely and room temperatures were monitored by the staff team. Medication administration records (MAR) were fully completed, and refusals were appropriately recorded.

We found ‘as required’ (PRN) medicines had the required protocols in place and the medicines stock checks we completed matched the records held by the service. Controlled drugs were stored appropriately with regular checks evident.

People and relatives told us staff made sure medicines were taken as prescribed. A person told us, “Yeah, they [staff] remind me I need to take my pills.” A relative told us, “They support [relative] to take his medication and record it safely.” Another relative told us, “Staff support [relative] with medication and record everything safely. When [relative] visits home it is all correctly packed and labelled in a blister pack.”

We found daily medicines audit forms and self-medication audits tools had not been consistently completed. However, we did not find this had impacted people and we were assured by the registered manager during the assessment this would be addressed and monitored for improvement.