Whitwood House

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 requires improvement. At this assessment the rating has remained 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 no longer in breach of legal regulation in relation to staffing. However, the service was in breach of legal regulation in relation to good governance.

This service scored 50 (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.

Concerns raised by relatives were not always appropriately responded to and lessons learnt to improve practice. For example, 1 relative told us they had raised numerous concerns with the registered manager and staff, however there had been no change to practice as a result. Records showed safety events were not always effectively reported and reflected upon to drive improvements.

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.

Systems and processes were in place to ensure people were safely admitted to the service. Pre-admission assessments were completed prior to a person moving into the service to ensure their needs could be met, including meeting the person face to face. Documentation regarding admission assessments was in place.

People were not always protected from the risk of abuse and avoidable harm. Systems and processes were not always robustly implemented to ensure timely reporting and effective monitoring of safeguarding concerns. The provider did not always share concerns quickly and appropriately.

Oversight of safeguarding concerns was insufficient. Information regarding the number of safeguarding concerns that had taken place within the service was not always accurate. The registered manager told us it was their responsibility to report safeguarding concerns to the local authority after their review of paper incident forms, completed by staff. However, there were significant delays in the review of these forms, by the registered manager, and therefore the provider could not demonstrate that safeguarding incidents were always identified and reported to the appropriate agencies in a timely manner.

Staff had received safeguarding training. They knew people well and were able to identify signs of abuse.

Risks to people’s health and safety were not always robustly assessed monitored and mitigated.

People were not always being weighed in line with their assessed need placing them at risk of harm. For example, 1 person was assessed as needing to be weighed weekly. They had not been weighed for a month. Another person had been assessed as needing to be weighed monthly. This had not been completed. Other records relating to weight monitoring were also incomplete and conflicting. For example, 1 person’s weight monitoring chart did not document their usual weight range or state the frequency they were required to be weighed.

Reviews of people’s care records were not always in place. Where they were in place they were inconsistent, and it was not clear whether information was always accurate, up to date and reflective of people’s needs. For example, 1 person had a positive behavioural support plan in place which had not been reviewed for 9 months. Another person had no care plan reviews in place. In addition, 2 people’s care records had not been updated following incidents. Therefore, the provider could not demonstrate that information was accurate and up to date to enable staff to support people safely. One relative told us, “I request to go and do care plan and risk assessment reviews. They say they will and then that never happens.”

The provider did not always detect and control potential risks in the care environment to support the delivery of safe care.

The provider did not always ensure the premises were secure to support people’s safety. For example, on the first day of the assessment the office door, leading to the outdoor area of one of the houses, was wide open, with no staff present. The office allowed unrestricted access to people’s living space and could be easily accessed by members of the public. This was discussed with the registered manager immediately who confirmed they would address this. However, later the same day the door was once again left wide open with no staff present. It was again discussed with the registered manager. On the second day of the assessment the door was again wide open, with no staff present. This meant the provider had failed to address a known risk.

Vehicle safety checks were not always fully complete. However, other maintenance and safety checks were complete. For example, fire safety and gas safety. Some aspects of the environment required updating. The provider had a plan in place to address this.

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 responded to people and met their needs without delay. They were knowledgeable and showed a good understanding of people they supported. Staff participated in supervision and training to aid them in their role, this included learning disability training.

Systems and processes were effective in supporting safe recruitment.

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.

The service was clean and odour free throughout. PPE was available for staff to use when required.

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.

Records relating to medicines at times lacked detail and were incomplete. For example, 1 person’s care plan did not contain information regarding how they take their medicines. Guidance was not in place for all creams applied by staff as part of personal care and some records contained gaps. In addition, guidance for how ‘when required’ medicines should be administered was not always person-centred and some was missing. There was no information when a variable dose was prescribed. There was a process for people to receive medicines when away from the service, however records were not always completed in line with this. Where handwritten entries were needed these were not signed or checked to ensure they were correct.

Medicines were not always stored securely. Access was not consistently restricted to authorised staff. For example, on day 2 of the assessment the office door, leading to the outdoor area of one of the houses, was wide open, with no staff present. The office allowed unrestricted access to the area where medicines were stored. The medicines keys were left unattended in the medicine cabinet. However, medicines were administered safely, and policies were in place to support this. Staff were respectful when supporting people and people received their medicines on time. The provider was following stop over medicating of people with a learning disability and autism (STOMP) guidance.