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 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 provider was previously in breach of the legal regulation in relation to safe care and treatment and staffing. Improvements were found at this assessment, and the provider was no longer in breach of these regulations.

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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider had made improvements and worked to develop a more positive culture of safety, based on openness and honesty; however, issues identified at our previous assessments in relation to good governance, had not yet been fully addressed or embedded, and we identified concerns around the management and oversight of the service.

Staff listened to concerns and understood how to report and escalate safety events. We reviewed accident and incident logs which were completed well and provided some evidence of root cause analysis and lessons learnt being shared with staff.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored, but further improvements were needed to ensure records consistently supported safe care delivery.

Staff worked with healthcare professionals including GPs, podiatrists and community nursing teams and people generally received prompt access to healthcare support when their needs changed. However, some care plans were found to be lengthy and difficult to navigate, with information duplicated across multiple sections. This provided limited assurance records were consistently maintained, and staff could readily access accurate information to support safe and effective care delivery.

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 had received safeguarding training, could confidently explain the different types of abuse, and understood safeguarding responsibilities and how to escalate concerns correctly.

Appropriate Deprivation of Liberty Safeguards (DoLS) referrals had been made to the local authority by the service. These referrals are part of the Mental Capacity Act 2005 (MCA), and people can only be deprived of their liberty to receive care and treatment with appropriate legal authority. We checked whether the service was working within the principles of the MCA and how they managed DoLS. Staff understood when DoLS authorisations would need to be sought, and what to do if there were conditions imposed.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Records relating to physical interventions, such as repositioning and continence care were not always sufficiently detailed or recorded accurately, for example, we saw that some people required repositioning at a 30-degree tilt, but there was no guidance for staff on what this was and how to ensure correct positioning. The care plans we reviewed were very lengthy and included duplicate information, which potentially made them hard for staff to follow. The management team recognised these shortfalls and had started to update care plans, strengthen documentation and improve the recording of related care tasks.

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

Some refurbishment work had been carried out since the previous assessment, including improvements to people’s bedrooms, furniture, communal areas, and décor. Maintenance checks were completed regularly, and any issues were actioned promptly. Staff and people’s relatives spoke positively about the charges to the home’s environment. A relative told us, “I think the home has done a good job of redecorating and providing new furniture in the rooms and lounge. It is always clean.”

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

Staff told us they knew people well and had received relevant training to carry out their roles. Staff were recruited safely, received regular supervision sessions and annual appraisals, and told us there had been improvements in leadership at the service, and overall morale.

We reviewed staffing rotas and the provider’s dependency tool which indicated enough staff were deployed to cover each shift; however, we observed times in the communal areas where no staff were present, and some staff and relatives continued to express concerns about staffing levels.

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.

We found improvements to infection control measures. The home was clean, well-presented and odour free. We observed a team of housekeepers working around the home to maintain good standards throughout our visit, and the staff we spoke with had a strong understanding of how to reduce the risk of infection by carrying out regular hand washing and wearing and disposing of appropriate personal protective equipment.

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

Medicines administration records reviewed contained no unexplained gaps or omissions and medicines governance was supported through regular audits. However,

we identified an issue around the recording of the amount of prescribed thickener used in fluids for 1 person on the homes electronic system. This put the person at risk of harm.

As and when (PRN) protocols were in place; however, some did not provide enough detailed information about the right dosage and when to administer. We discussed this with the manager who advised the concerns would be addressed.