West Ridings 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 inspection we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of 2 legal regulations in relation to people’s medicines, risks were managed and lessons learnt from incidents, and the lack of an effective system to ensure safe staffing levels were in place.

This service scored 34 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The systems in place to record and monitor accidents and incidents at the service were not being used effectively to ensure actions were taken in a timely way and lessons learnt.

Issues around a high increase in falls and wounds, skin tears and bruises happening at the home had been identified, but this information was not used to review staffing levels or take other appropriate actions to prevent reoccurrence.

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.

While initial assessments were completed, we found people’s care records lacked information to ensure they received safe and consistent care by staff at West Ridings Care Home.

Before our assessment, we received information raising concerns about the provider’s working relationship with community healthcare professionals. During this assessment, we received feedback from 1 healthcare professionalwho referred to the same concerns. They told us that while some improvement had been noted since the new interim home manager was appointed, this had only been implemented after concerns were raised with the local authority safeguarding team.

During our assessment, we found the provider was not ensuring that people accessed the care they required from their GP and dietitians, in a timely manner.

The provider did not always work well with people and healthcare partners to understand what being safe meant to people 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 share concerns quickly and appropriately.

Although staff had received training in safeguarding adults, and staff and managers told us they knew who to contact if there were safeguarding concerns, during this inspection we identified safeguarding concerns that had not been acted upon and reported by staff. We raised safeguarding concerns about 1 person being physically abused by another person living at the home while in the communal area. We asked the provider to raise an organisational safeguarding concern due to several people living at the home losing weight or continuing to lose weight and appropriate action not being taken by the provider.

The provider was not always working within the principles of the Mental Capacity Act 2005 (MCA) because there was a lack of oversight to ensure Deprivation of Liberty Safeguards (DoLS) authorisations were in date andhad been applied in a timely way.

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.

We found widespread concerns about people’s safety and actions not being taken in a timely way.

The system in place to monitor people's weight had not been effective in identifying and taking timely action in relation to people at risk of losing weight or continuing to lose weight. We shared our concerns with the provider and asked for an update. On our second visit to the home we found that the provider had identified several people who had lost weight, continued to lose weight or had known health concerns which required additional monitoring and referrals to the GP; this had not been identified before our assessment. We shared this information with the local safeguarding team. After our assessment, the provider updated us on the actions taken in relation to these concerns.

People who were at risk of falls did not always have risks safely managed. People’s risk assessments and care plans were not always accurate or provided specific guidance to staff.

Risks to people’s skin integrity were not well managed.Some people living at the home were at risk of developing issues with their skin integrity. They required regular repositioning, creams to be applied and had equipment in place such as air flow mattresses to ensure this risk was well managed. However, we found people’s air flow mattresses were not always set at the correct setting according to their weight and records did not always evidence people had been repositioned at the recommended time. During and after our assessment, we received an update confirming action had been taken by the provider in this area.

The provider did not always detect and control potential risks in the care environment.

The provider was conducting regular checks to the environment and taking action when appropriate. Overall fire safety was well managed, however we found staff had not completed regular fire drills and concerns identified by the provider at the last fire drill completed in January had not been followed up. We discussed our concerns with the interim manager who told us fire drills would be completed with all staff in the upcoming weeks.

Before our assessment, we were made aware of an incident where a person living with dementia attempted to leave the service unsupervised via the garden. During our first visit, we observed the units’ gardens and found no action had been taken to manage the risks identified. We expressed our concerns to the interim manager and on our second visit we found improvements had been made.

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.

People, relatives and staff raised concerns about staffing levels. People’s comments included, “No, there are not enough staff, they are always very busy. They do their best but have too much to do. They don’t have time to chat to you, which would be nice.” Relatives told us, “Quite a few times, there isn’t enough staff. They are so busy, they haven’t got time for anything else” and “No, there are not enough staff, they are all really busy. For the size of the unit, they need more staff as there are a number of people who need to be hoisted and need two carers.”

During our visits, staff also raised concerns about staffing levels not being enough. A staff member told us, “At the moment [staffing] is not good”. We reviewed the results from the recent staff survey completed in January 2025 and several staff members raised concerns about staffing levels.

We found examples of people’s dependency assessments not being reflective of their needs and analysis from accidents and incidents such as falls and bruises was not used to review staffing.

After our assessment, the interim manager told us staffing was being reviewed and additional staff had already been put in place.

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 followed the provider’s infection prevention and control policies. We found personal protective equipment (PPE) was available and staff used this appropriately. We observed staff completing cleaning duties regularly.

People and relatives gave positive feedback about the cleanliness of the service. Comments included, “I do think it’s clean. I do see the domestic staff coming in” and “Very clean, they clean my room and bedding.”

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

While we found people mostly received their medication as prescribed, we found concerns in other areas of medicines management.

At our last inspection, we found that medicines required by law to have additional controls, called controlled drugs, were not stored in the way required by law. At this assessment, we continued to find controlled drugs were not being stored in a cabinet in line with requirements.

We found the system in place to measure and record the fridge temperatures on a daily basis had not been effective in identifying and addressing concerns. We found insulin had been stored under the temperature required and no action had been taken. We shared this with the provider and after our assessment we were informed appropriate action was taken.

We found concerns with protocols for medicines to be taken ‘as and when’ required not being detailed enough about the reasons for administration which meant not enough guidance was given to staff to ensure people received consistent and person centred care.

We found the provider did not have in place the required records to ensure that people who had been prescribed anticipatory medication, would receive this in a timely way.

The issues with medicines management had not been identified in the provider’s own medicines audits.