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 assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment and staffing.

This service scored 38 (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 service recorded accidents and incidents, and actions were generated to investigate these. However, we could not be assured by the evidence reviewed that these actions were completed or followed up in a timely manner. This meant appropriate actions to prevent reoccurrence were not always evidenced and lessons learnt consistently shared with staff. The management team gave us specific examples of when lessons learnt had been shared with staff, but evidence reviewed did not show this was regular practice.

We continued to find issues with a high number of falls, skin tears and bruises happening at the service. For example, there had been incidents where people who were bed bound and required full support from staff to mobilise had skin tears and unexplained bruises.

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.

During our assessment, we spoke with a visiting professional, and we received written feedback from a group of professionals. Professionals told us they would not want to have one of their relatives living at the service. This was due to continued issues with lack of consistency of management, staff not always knowing about people’s needs and some specific clinical concerns about staff’s knowledge and approach. The management team at the service told us about the action they had taken to improve working relationships with visiting professionalssuch as regular meetings.

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.

There were safeguarding policies in place, and we found examples of the provider reporting safeguarding concerns as required. Staff had received training in safeguarding adults; and staff and managers told us they knew who to contact if there were safeguarding concerns. However, we found the systems in place were not operating effectively. We found continued safeguarding concerns raised about unexplained bruising, but a lack of action by the management team to investigate and prevent reoccurrence, including for people with reduced mobility who required staff’s support to meet their needs. Repeated incidents of unexplained bruising without sufficient action to investigate meant people were experiencing repeated harm, without evidence of robust action taken by leaders to investigate, look for trends and improve staff’s practice. During our assessment, we had to request the registered manager to a submit safeguarding referral because a person made an allegation against a staff member. We received confirmation from the service that they had made the appropriate referral.

We continued to find risks to people were not well managed. 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.

Risks to people's skin integrity were not safely managed. We found continence care and repositioning was not always occurring in line with people's requirements and best practice guidance. Some people were at risk of developing issues with their skin integrity and required regular repositioning to ensure this risk was well managed. Records did not evidence people had been repositioned at the recommended times, and some people had developed skin moisture lesions and pressure ulcers. We found examples of people not being regularly supported by staff to meet their continence needs.

Risk of falls was not well managed. We found people did not always have access to adequate supervision and equipment required to manage their risk of falls such as Zimmer frames and sensor mats.

We found concerns with the provision of catheter care and people having their meals in bed in semi reclined positions which posed them at high risk of choking. These concerns had not been previously identified before our visit. We shared our concerns with the management team, and we found some improvements had been made on our last visitsuch as evidence of people’s catheter bags being emptied by staff more regularly and relevant care plans in place.

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.

We found examples where the environment was not safe for people including people having access to areas that were not safe for them. Some areas of the service, including inside people’s bedrooms, were damaged or required decoration. The provider had a refurbishment plan in place

We shared our concerns about the environment with the management team and action was taken or we were informed of the ongoing work to improve the home’s environment.

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.

We continued to find the service was not always using the information available to monitor the safety of people and ensure staffing was managed safely to meet people’s needs.

During our visits to the service, we found staff were not always deployed safely, and we found examples of communal areas being left unattended or staff not taking action to manage risks to people. For example, we observed a person who was at high risk of falls and required supervision while mobilizing not being supported by staff as required.

Feedback received from people, relatives, and staff indicated concerns about staffing. People told us, “They never have enough staff. When there’s a few staff on they are rushed off their feet” and “I waited and waited and waited. They [staff] say they help who’s worse off” and “No [not enough staff] I see them run ragged.” Relatives told us, “Staff seem to be overworked” and “At times they have seemed short staffed to me, yet at others they seem to have enough staff.” Staff commented, “Sometimes there is [too] much work [for the number of staff on shift]” and “[Staffing levels] are not good with the type of residents we have” and “I think staffing might be a bit low.”

The provider was using a dependency tool to assess the level of staff required according to people’s needs; however, deployment was not always well managed by effective management oversight in the day-to-day delivery of care.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We found regular cleaning was happening at the service however there were examples where areas of the service were not clean such as in some people's bedrooms or in the clinical room.

People and relatives shared mixed feedback about the cleanliness of the home and quality of the environment. Their comments included, “They keep the home clean” and “It is a cleanish home” and “It could go up a level in cleanliness. I feel that it needs a deep clean from time to time” and “I keep being told the room’s going to get refurbished, this hasn’t happened” and “The carpets are filthy.”

One person who have us feedback invited us to visit their bedroom, we noticed their bed was not made and they commented, “If you had come in without the carer, the bed would never have been made. My bed would never have been made from one morning to the next.”

We shared our concerns with the management team we were informed of the ongoing work to renovate the home and to improve infection and prevention practices.

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.

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

‘As and when’ required medicines continued to not be well managed and administered. We found the information available to nursing and care staff who administered these medicines was not sufficient to inform the staff of how and when it was appropriate to administer them. There was also no information about whether the administration of these medicines had been effective. We found concerns about the high frequency a person had been given ‘as and when’ required medication to manage their behaviour when it was not evidence why they needed it.

We found the quality of diabetic care plans was not consistent and we found examples where records were not sufficiently detailed to ensure safe practice of diabetic medicines.

Transdermal patches to manage pain relief were not always applied in line with manufacturer’s instructions.

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

At our last assessment we found concerns about the system in place to measure and record the fridge temperatures and storage of controlled drugs. In our sample of records, we found improvements had been made in these areas.