Walsingham Support - 1 Ashley Close

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 provider was in continued breach of the legal regulation in relation to safe care and treatment and we identified a new breach of regulation for staffing.

This service scored 53 (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 or report safety events. Lessons were not always learned to continually identify and embed good practice. There was a lack of information recorded when accidents or near misses occurred. During a site visit, we observed someone on a soft diet eating from another person’s plate. Staff were unconcerned, saying, “They always do this,” which indicated a lack of awareness about safety protocols. Additionally, there were no clear procedures for staff to record accidents or incidents, and while paperwork was sometimes completed, regular reviews to identify trends or learning opportunities were missing.

We did however see improvements to systems and recording of information since the new registered manger had started.

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 ensure there was continuity of care, including when people moved between different services. There was a high rate of staff turnover, and incomplete documentation occasionally led to important information about people being missed. For instance, one person benefited from a specific aid for reassurance but did not have access to it for an extended period. When the new registered manager became aware of the situation, the item was purchased immediately. Additionally, some significant details were included in care plans without being communicated to the registered manager. This meant the registered manager did not always have the most up-to-date information.

We received feedback from a professional who told us they are working well together now after some historical issues, and they felt there was open communication and dialogue which helped support people better.

Relatives told us they felt their loved ones were safe.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them 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 promptly or through appropriate channels. On two occasions, safeguarding concerns were not reported to the local authority or the CQC as required. Additionally, the outcomes of some safeguarding concerns were not always clear. Senior staff acknowledged that, due to a managerial transition, there were instances when the storage location of information was unclear. During the assessment the inspector saw how improvements to record keeping and monitoring had been introduced.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care that was safe, supportive, and enabled people to do the things that mattered to them. Information documented in people’s risk assessments was at times incorrect or inconsistent. For instance, it was sometimes unclear which details were accurate for those supported by the Speech and Language Therapy (SALT) team.

Staff reviewed risk assessments and noted “no changes”,despite their having been some changes that were not identified. The registered manager acknowledged the requirement to review and update all risk assessments.

We also observed a staff member pushing someone in a wheelchair without asking the person to raise their feet – this placed them at risk of injury. This example highlighted a lack of attention to safe moving and handling practices, which could have resulted in harm to the person involved.

The provider detected and controlled potential risks in the care environment. They ensured that equipment, facilities, and technology supported the delivery of safe care. The registered manager had systems in place to manage the environment. An annual fire check had been carried out, and the majority of outstanding tasks had been completed in a timely manner. Regular fire testing was conducted, and people had up-to-date Personal Emergency Evacuation Plans (PEEPs) to guide staff on the support required during a fire. Additionally, grab bags were prepared with essential items for evacuation.

The provider did not always ensure there were enough qualified, skilled, and experienced staff. They did not always work together effectively to provide safe care that met people’s individual needs. There were not enough staff to care for people safely. The registered manager and senior staff stated that the staffing model was determined by the funding allocated from the local authority, noting that staff numbers could be difficult to maintain at times. For instance, on the first day of the site visit, one person required assistance to go outside, but there were not enough staff available for this activity. On the second day, the inspector observed situations where additional staff in the lounge may prevented certain incidents. The registered manager reported efforts to document reasons why some people require more staffing hours but noted gaps in evidence due to incomplete recording by staff.

Staff were recruited safely. Staff told us they received induction and training when they started working for the service, as well as ongoing refresher training for mandatory areas such as safeguarding and moving and handling. Training records reflected this.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns withappropriate agenciespromptly.Guidance on good hand washing techniques was displayed in toilets and bathrooms. Staff also received training to support with infection prevention and control (IPC).

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

The service did not have risk assessments in place for people who were using emollient creams. This omission meant that potential risks associated with the use of these creams were not formally identified or managed.

Additionally, the medicine administration records (MARs) for some people included medications that were no longer prescribed to them. The registered manager was uncertain whether these medicines should still have been prescribed,indicating a lack of clarity regarding current medication.

However, medicines were stored safely in the home, and the service supported people in receiving their medicines safely away from the home.