Westbury 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. At our last assessment we rated this key question good. At this assessment the rating 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 regulation in relation to safe care and treatment.

This service scored 59 (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. Regular meetings were held to share learning. Incidents were recorded and investigated. Staff were aware of the processes to record incidents and escalate concerns if needed, they told us learning was shared with them during team meetings.

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. People’s care records evidenced people’s needs and preferences to enable them to transition safely. The provider had systems to support interaction with others such as advocacy services. The provider had documents to share with healthcare professionals such as hospitals when support was shared.

The provider did not always work well with people to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The provider did not always adhere to the principles of the Mental Capacity Act or ensure that people’s rights were safeguarded. For example, a person was using the en-suite facilities of another person who lacked capacity to agree to this. The provider had been open and transparent with other professionals in relation to this. However, a decision had been made which could not be shown to be in the person’s best interest. This meant the person was at risk of discrimination and their rights not being upheld.

However, the provider had authorisation records related to people’s deprivation of liberties. Staff had received training and were able to explain how they would safeguard people. People told us they felt safe and liked living in their home.

The provider did not always work with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe. Potential risks had been identified and control measures were put in place for people. However, control measures were not aways the least restrictive option. For example, actions to reduce the risk of a person choking involved locking a cupboard door. There was no evidence that this was in the best interest of all people living at the service. The Registered Manager informed us the key was held by a senior staff member. This meant every person who wished to access the cupboard was restricted in doing so freely.

During our visit, works were being carried out on the environment. The service had a general health and safety risk assessment in place which included risks relating to maintenance works being carried out. However, this general risk assessment stated, ‘Risk assessment to be in place for all refurbishments and projects affecting the site'. However we observed some tools, such as electric saws, which had been left unattended in the corner of a garden. This increased the risk of harm to people.
 

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 provider had risk assessments related to the environment and completed regular fire evacuation drills and safety audits. However, Lighting in some areas, such as the upstairs corridor, was poor. As the provider supported people with sight and mobility difficulties, this increased the risk of trips and falls to people. Despite this, there was no evidence people had fallen due to the poor lighting at the time of our inspection. in addition Staff told us that the cess pit produced an offensive smell. One comment included " its not nice sitting out there ". The provider had increased the frequency of emptying this and financing improvements to the cess pit this had not eliminated the smell.

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 completed training relevant to their role, to enable them to support people safely. The provider supported staff with regular supervision. Staff were deployed in line with the services dependency tool. People told us they liked staff.

The provider did not always manage the risk of infection. They did not always detect and control the risk of it spreading. Staff told us they had access to personal protective equipment such as gloves and aprons and knew how to use this appropriately. The provider had schedules for cleaning. However during our visit we saw that the fridge was not clean. Additionally, we observed faeces in a communal bathroom. This put people at risk of infection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. For example, not all staff were familiar with guidelines in relation to Stopping Over Medication of People with a learning disability, autism, or both (STOMP). STOMP is an NHS England initiative designed to reduce the inappropriate or excessive use of psychotropic medications.

Medicines records were not always fully competed. For example, we saw the controlled drugs record had not been completed in line with best practice. We also saw that a person’s Medicines Administration Record (MAR) was not fully accurate. We found that on one occasion staff had not signed for a controlled medicine.On two occasions, staff had not signed for medicines they told us had been administered, this record was amended when we highlighted the gap. Leaders told us they would have identified this during their audits.

The provider had not always produced medicines guidance for staff to follow. For example, one medicine needed to be taken at least 30 minutes before food or caffeine. If this was not done it could impact how well the medicine worked. Leaders told us the person chose not to follow this guidance, and we saw evidence this had been agreed by the person’s GP. However, there was no clear information for staff to inform them this guidance did not need to be followed. This meant there was a risk of new staff administering medicines against the person’s wishes or agreed guidance. However, there were risk assessments in place for emollient creams and medicines were stored in people’s own rooms safely. Staff had completed training to support medicines.