Wendleberrie 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 Good. At this assessment the rating has remained Good.

This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were systems in place to review accidents and incidents to understand what had happened and identify actions needed to reduce the risk of similar events occurring again, the provider discussed learning with staff However, lessons learned were not always clearly recorded or detailed enough to show how learning had been shared and used to improve practice. This meant opportunities to embed learning and improve safety were not always fully achieved.

The provider acknowledged this and has decided to introduce a more detailed lessons learned record. This will be shared with staff, who will be required to read and sign it to confirm their understanding of any actions and improvements identified.

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.

There were processes in place to support safe admissions, transfers and ongoing care. Initial assessments were completed before people moved into the home to ensure their needs could be met safely. People, their families and relevant healthcare professionals were involved in assessments to help ensure care was planned appropriately from the outset.

Hospital transfer packs were prepared and readily available for use when required. These were reviewed every three months, or sooner if there were any changes to a person's needs. The packs contained clear and detailed information about people's health conditions, care needs, medicines and abilities, helping to support safe transitions between services.

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.

The provider had systems in place to help protect people from abuse and avoidable harm. Where people lacked the mental capacity to consent to their care arrangements, applications for Deprivation of Liberty Safeguards (DoLS) had been submitted appropriately. The management team demonstrated a good understanding of the DoLS process and knew when applications were required to ensure people's rights were protected.

People and relatives told us they felt safe in the home and around staff. One person told us, “Ooh yes, the safest place I have been in is here,” and another relative told us, “I have no issues with her safety. I go home and don’t worry.”

The provider submitted statutory notifications as required and had processes in place to identify, record and respond to safeguarding concerns. The registered manager understood their responsibilities under the Duty of Candour and promoted an open and honest culture when things went wrong.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff demonstrated a good understanding of the risks associated with people's care and support needs. Individual risk assessments were completed. People living with diabetes had person-centred risk assessments in place which included guidance for staff on recognising and responding to signs of high and low blood sugar levels. People on prescribed anticoagulant medicines also had specific risk assessments with appropriate guidance to help staff manage associated risks safely.

Where equipment was used that could potentially restrict a person's freedom, such as bed rails or sensor mats, records showed that people, their relatives and relevant professionals had been involved in decisions about their use, where appropriate.

The provider did not always identify and manage potential risks in the care environment. They did not always ensure the premises, equipment and facilities supported the delivery of safe care.The provider's fire risk assessment identified a number of actions requiring improvement, including some assessed as serious breaches. At the time of assessment, several actions remained outstanding beyond their expected completion timescales, and the provider was still arranging surveys, training and quotations to address some of the identified actions.Building works were taking place during the inspection, resulting in changes to communal areas and the relocation of furniture and equipment, which reduced the space available for people, visitors and staff.

This meant the provider could not demonstrate that identified fire safety risks had been addressed in a timely way or that the risks associated with the temporary changes to the environment had been appropriately assessed and managed.By the end of the assessment, the provider gave assurance that appropriate measures had been put in place to address these concerns.The environment was generally safe, clean and well maintained. Wardrobes were secured to reduce the risk of injury, and the home was well lit with clear signage and wide corridors that were free from hazards.

Personal Emergency Evacuation Plans (PEEPs) were in place for people who required support in an emergency. Fire drills had been carried out regularly every six months.Equipment used to support people was easily accessible to staff and stored safely when not in use. Statutory safety checks relating to the premises and equipment had been completed by the provider or approved contractors.

The provider did not always ensure staff had the knowledge and skills needed to provide safe care or consistently follow safe recruitment processes. However, there were enough staff to meet people's needs safely.

At the time of the assessment, compliance with mandatory training was low, including in key areas such as fire safety, first aid, the Mental Capacity Act and person-centred care. This meant the provider could not demonstrate that all staff had the knowledge and skills needed to provide safe care. The provider took action to improve training compliance and provided updated records showing that completion rates had increased.

Agency staff were used when required to maintain safe staffing levels. Where agency staff were used, the provider aimed to use regular agency staff to promote continuity of care. Staff received regular supervision and appraisals to support their role. Feedback from people, relatives and staff indicated there were enough staff on shift to meet people’s needs. A person told us, “The staff are very attentive and very helpful." Another relative told us, "There's always enough staff, it's been steady staff wise for the last three years."

Recruitment records generally included the required pre-employment checks. However, we found gaps in recruitment records for some staff. For example, employment references from the most recent employer had not always been obtained, and where references had been requested, the provider could not demonstrate that appropriate follow-up action had been taken when no response was received.

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 provider had infection prevention and control policies. Cleaning schedules were in place, and records were up to date at the time of the inspection. The home was clean, tidy and free from unpleasant odours.There was a sufficient supply of personal protective equipment (PPE) available for staff to use. Safe food hygiene practices were followed. For example, opened food items were clearly labelled with the date they had been opened to help ensure food was stored and used safely. A relative told us, "No odours around the home anywhere I went." Another relative told us, “Relatives room is immaculate and they change (relatives) bedding, it’s always clean.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The provider had systems in place to support the safe management of medicines, including a medicines policy, regular medication audits and an electronic medicines administration record (eMAR) system.Medicines were stored securely and were only accessible to authorised staff. Storage temperatures for medicines and refrigerators were monitored and were within the recommended ranges at the time of the assessment. Liquid medicines and topical preparations were dated when opened.One relative told us, “(Relative) is on a regime of medications. Yes, they (staff) make sure (relative) takes them regularly.”We checked medicine stock balances for a sample of people and found no discrepancies. PRN (as required) protocols were in place to guide staff on when these medicines should be administered. Where people received covert medicines, appropriate assessments, authorisations and supporting documentation were in place.

We identified some areas for improvement in medicines management. For example, one controlled drug had remained in use beyond the manufacturer's recommended period after opening, and routine stock balance checks for controlled drugs were not always recorded. We also found some expired items in the first aid and trauma care boxes. The provider took immediate action to address these issues during the assessment.