Wellesley Lodge

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. This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

Staff were aware of their reporting requirements and documented any incidents or accidents that occurred. The management team reviewed individual incidents to ensure appropriate action was taken to learn from and support the person, as well as regular review of all incidents to identify any themes and trends.

Staff took the time to reflect on any serious incidents that occurred or safeguarding concerns that arose to implement learning and improve practices.

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.

Staff worked with the local authority, hospital staff, the person and their family to support with transitions to the service. They gathered all information available through the pre-admission process to identify people’s support needs and how they wished to be supported.

The home worked closely with other healthcare professionals and hosted training on the ‘red bag scheme’ to aid staff’s understanding about how to use the bag to support smoother transitions when people require admission to hospital.

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.

Staff were aware of and adhered to their responsibility to safeguard people from avoidable harm. Staff had completed safeguarding adults training and understood how to recognise and report safeguarding concerns. Staff worked with the local authority safeguarding team to investigate and learn from safeguarding events that occurred.

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 people were only deprived of their liberty when there were legal authorisations in place to do so to keep people safe.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff assessed risks to people’s safety. Risk assessments were reviewed regularly and as people’s needs changed to ensure management plans continued to address people’s needs. Where people required it, equipment was put in place to support people and minimise risks to their safety. This included equipment to support with their mobility, reduce the risk of pressure wounds, as well as sensor mats and call points to alert staff should people need additional support. Staff worked with the falls prevention team to obtain specialist advice about how to further support people. People told us, “[Staff] are brilliant at checking in on me” and “In my room I have a device which beeps and alerts staff when I get up. Very soon after a member of staff would appear and offer support.” A relative told us their family member had the right equipment in place to support with identified risks and “This gives me confidence that they are thinking seriously about [their family member’s] safety.”

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

A safe environment was provided and the provider ensured equipment and facilities were regularly serviced. Fire safety equipment was available throughout the service and people confirmed that staff supported them to practice fire evacuation drills, so they knew what to do in the event of a fire. A secure environment was provided. People had access to courtyards and a large garden to ensure people had access to daily fresh air.

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.

Safe recruitment practices were in place to ensure suitable staff were employed. The management team regularly reviewed people’s dependency level and used this information to determine staffing levels. A relative told us, “There always seem to be sufficient staff when we visit and they seem well trained and proactive in care and support.” We observed staff being visible and regularly engaging with people and responding to their needs. Staff felt at most times there were sufficient staff to enable them to do their duties and provide people with the support they required. However, staff felt in specific instances staffing levels were stretched. The management team were in conversation with the local authority about staffing levels and funding for one person’s specific needs, which would help address this concern.

Staff received regular training and staff were up to date with the provider’s mandatory training. The provider encouraged staff to develop their skills and supported career progression. Staff received regular supervision and attended staff meetings to ensure they were supported in their role.

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 received training in infection prevention and control (IPC). The provider had IPC policies in place and undertook regular audits to ensure compliance. Staff confirmed they had access to personal protective equipment (PPE), and we observed staff wearing it appropriately. We observed a clean and hygienic environment was provided and people confirmed that high cleanliness standards were maintained. One person said, “Hygiene is very important here… having my room cleaned daily lifts my spirits.” Another told us, “I receive help with cleaning my room every day. The cleaner is an absolute star. She is an example of someone with love and care.”

Overall, the provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Safe systems were in place for the ordering, storage, administration and disposal of medicines. We saw accurate records were maintained of the medicines administered. However, since the move to an electronic medicines system there were some discrepancies with the records relating to medicine stock counts. We observed incorrect stock counts being recorded on the system, meaning the number of medicines on site did not tally with the number recorded on the system, increasing the risk of medicines errors. The management team told us there had been some initial problems with the system. They confirmed shortly after our visit this had been addressed with the system provider and accurate stock totals were now maintained.

The staff worked with people’s GP to ensure regular medicines review. This included removing and minimising the number of medicines people took when appropriate. For example, staff worked with the GP to remove one person’s medicine because they were concerned about their side effects and the impact this had on the person’s risk of falling.