Winscombe 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 good. At this assessment, 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 regulation in relation to safe care and treatment, including, safeguarding service users from abuse and improper treatment, staffing and notification of other incidents

This service scored 47 (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 and positive culture of safety based on openness and honesty. Whilst staff told us the registered manager was available and responsive to concerns, records failed to detail lessons had been learned relating to incidents of possible abuse.

People and their relatives told us they had received good support when they moved into Winscombe Care Home. Staff had worked with other services to ensure people received continuity of care, for example, liaising with existing care providers and community health services already known to the person.

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, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. The provider did not consistently share concerns quickly and appropriately. Staff we spoke with were familiar with the adult safeguarding policy and procedures. However, the provider failed to submit statutory notifications to CQC as required by law when abuse was suspected. For example, the provider’s safeguarding records detailed 2 cases of possible abuse, neither of these had been notified to CQC. Providers are required to inform us when people are subject to Deprivation of liberty safeguards (DoLS). At the time of our inspection, the providers records stated 12 people had these safeguards in place, but only 7 notifications were provided to us. The registered manager submitted these retrospectively.Arrangements regarding the management of people’s money were not sufficiently robust to ensure people would always be protected from financial abuse.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. For example, one person had a falls risk assessment in place. The actions on how to support this person to mitigate risk of further falls were not completed. A second person’s care plan stated they should be supervised when smoking. On 3 occasions, we observed the person smoking in their room without supervision and without an ashtray. People who had been identified as being at risk of choking were not always supported to eat and drink safely. We observed one person violently coughing whilst eating their lunch. Staff failed to respond appropriately and we had to intervene. This person’s care records were contradictory in terms of the texture of food required to reduce the risk of choking. This meant staff were not aware of the risk associated with people and how to respond appropriately.

Staff liaised with local professionals to make sure people had the equipment they needed. The registered manager told us they would not admit a person to the home until all appropriate equipment were in place, staff contacted healthcare professionals for advice or guidance to ensure they used any equipment safely. External contractors completed health and safety assessments in relation to fire risks, infection control and water safety to ensure the environment remained safe.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. For example, staff had not received training in respect of cerebral palsy despite several people living with the condition. Staff competence in relation to percutaneous endoscopic gastrostomy(PEG tubes, allow you to receivenutritionthrough your stomach if you have difficulty swallowing or cannot get all the nutrition you need by mouth) and the administration of medicine was not monitored or assessed effectively. We observed staff administering medicine without having completed their medication training and having their competence assessed. We saw one staff member administer a controlled drug on their own when 2 staff should have supported the process. The provider had not checked the content of training they commissioned to ensure for example it provide staff with the knowledge to administer insulin safely. This placed people at potential risk of harm. However, effective recruitment procedures were in place and staff told us they felt supported in their role.

People and their relatives told us staff followed good infection control measures. Staff demonstrated a good understanding of infection prevention and control processes they should follow and said they had received training. Staff said they never had any problems obtaining the personal protective equipment they needed. The provider had an infection prevention and control policy, which was regularly reviewed and updated to reflect current guidance. The management team completed regular checks and observations of staff, to ensure they were putting the procedures and their training into practice.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning, and we could not be assured medicine was always provided when required. Guidance relating to one person’s medicine confirmed a gap was required between the administration of 2 particular tablets. The person’s medication administration record (MAR) evidenced these medicines were not always administer with sufficient time between doses. On the first day of our inspection we identified 16 people had not received their morning medicine by 11:11am. We identified gaps in MAR for various people and had concerns about the competence of staff to manage medicine safely. Staff were not always appropriately trained in respect of administering insulin or in their ability to use an EpiPen safety. The provider failed to ensure medicine placed in the fridge were stored at the correct temperature in line with best practice guidance. The provider was unable to demonstrate how lessons were learned in response to medication errors.