Watermoor 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

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.

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 in breach of the legal regulation in relation to people’s safe care and treatment.

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.

Staff did not always listen to concerns about safety and did not always investigate and report safety events. The leadership team did not always ensure lessons were learnt to continually identify and embed good practice.

Leaders were working to embed a learning culture. Staff told us they felt confident to raise concerns and to report incidents, and they discussed how things could be improved at staff meetings. Incidents were well documented, however, learning from incidents was not always evident and there were instances of repeated similar incidents. This placed people at risk of harm as actions by the registered manager had not always been taken to mitigate identified risks. The provider did not have a system or process to record lessons learned from investigations into safeguarding incidents or complaints. Where safety events had already occurred, there was not always a well-resourced and proportionate approach for responding to them. For example, after some incidents had occurred, managers identified a need for staff training on positive behaviour support. However, this training need was repeatedly identified after several incidents and had still not occurred at the time of inspection. This meant similar, repeated incidents continued to occur, which put people at risk of receiving inappropriate support and responses from staff.

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.

Care and support were planned and organised with people, together with partners and communities in ways which ensured continuity of safe care. A healthcare professional who worked with the service told us, “The staff appear to know people very well and staff are always friendly, supportive and caring […] The staff are helpful and always facilitate visits from health professionals when needed. They have always been very supportive in setting up multidisciplinary meetings with residents and their families in complex cases.” The service was working within a local initiative to improve falls management and associated skin integrity care.

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 understood their responsibilities in safeguarding people and knew where to access policies and support. Staff received safeguarding training and told us they felt able to approach managers with any concerns. Staff told us, “The training has told me any safeguarding concern must be recorded and reported” and “we have all the information we need to support people safely”. Managers made appropriate and timely referrals for people who lacked mental capacity. The registered manager kept a tracker of Deprivation of Liberty Safeguards applications sent which included when people’s authorisations ran out, conditions and who was responsible for sending renewal applications. While people living at the service mostly told us they felt safe, 1 person told us they felt concerned about how they would be evacuated in the event of a fire, and they had raised this with staff.

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.

Individual risks were not always adequately assessed, and people were not always appropriately involved in this. For example, we found people’s care plans did not always detail and provide information to mitigate person-centred risks experienced by people, such as risks of absconding from the service, and people’s risk of falls. We did not see evidence of people being actively involved in positive risk taking or in the managing of their own risks.

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.

The provider had not always identified and mitigated environmental risks to people. We found there were unsafe areas in the care environment which were accessible to people, for example an open stairwell where moving and handling equipment was being stored, and unrestricted access to the laundry room accessed from an external courtyard which was in disrepair and not safe, being used to store soiled linens. We also found a large window without a window restrictor on the second floor of the building. The registered manager confirmed this was being rectified as a matter of urgency. This meant unsafe areas were accessible to people, putting people living with dementia at risk of harm. Since the inspection, the registered manager has made improvements to these areas and mitigated the risk of people coming to future harm.

Staff did not always work together well to provide safe care that met people’s individual needs.

Staff told us that they felt there were enough staff to meet people’s needs, however some people and family members told us at times it felt like there were not enough staff on duty. The provider did not have a process of auditing staff response times to call bells and therefore could not monitor the length of time people would wait to receive help and support. The provider was receptive to feedback and we saw evidence a new system had been implemented to assess call bell response times through spot checks. The provider used a dependency tool to calculate staffing numbers; however, we identified there were no housekeeping or laundry staff scheduled to work on Sundays, creating a gap from Saturday afternoon to Monday morning. This put the service at risk of being short-staffed due to having to cover housekeeping duties. One person living in the service told us, “It feels a bit short of staff, especially at weekends”. We found the provider had a thorough recruitment process to safely recruit staff. Disclosure and Barring Service (DBS) checks are a criminal record check used by employers to review information on an applicant’s criminal history to make safe recruitment decisions. The provider ensured DBS checks had been completed for all staff members, however they did not have a robust process to ensure original DBS certificates were seen and verified. There was a risk if original certificates were not viewed people could be working at the service who had recorded criminal convictions the service was not aware of. Since our inspection, the provider has implemented a system to ensure original DBS certificates are verified.

We identified some areas for improvement in relation to infection prevention and control. While the service was clean and free of malodours, we found hazardous cleaning chemicals being stored in an accessible area, which meant people living with dementia may access these. Since our assessment, the provider has taken action to improve the safety of these areas and has made changes to mean chemicals were stored securely, and storage areas were locked when not in use. Staff received training on infection control; however, staff had not read the infection control policy as it had not been available to them. This meant there was a risk of staff being unable to protect themselves and people using the service as they were unaware of infection control procedures. Since the inspection, we have received assurances the policy has been made available to staff.

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.

We had concerns with how medicines were managed, which meant regular reviews were not always documented correctly. The provider did not have a clear schedule for medication reviews. The provider did not have a robust process for auditing medication management to identify and mitigate risks, which put people at harm of not receiving medicines in accordance with best practice guidelines. We were therefore not assured the manager had safe and effective oversight of medication management in the service. For example, managers relied upon informal updates from staff on whether there were any issues with medication. This meant errors in administration could go undetected, and staff members’ actions were not being effectively reviewed and monitored to ensure they were adhering to best practices. The service had recently transferred to a new electronic system for medication administration recording, however because of the lack of effective auditing, there had not been safe oversight of this process by either the medication staff members or the registered manager. We found an electronic audit tool had at times been used in the service, however this was brief, unclear and did not use standardised terminology. This put people at significant risk of harm as administrative or prescribing errors were less likely to be noticed and resolved. Some people were prescribed medicines which were to be administered 'as required', however the service did not have protocols to inform staff of clear guidance to follow, including when to administer or how to review the effectiveness of these medications. This put people at risk of being given medication ineffectively and not in line with the medication information contained within their care plan, for example for an inappropriate reason or at an inappropriate time. Medicines, including controlled drugs, were stored securely and at appropriate temperatures. However, staff did not adhere to safe medication practice such as completing controlled drugs stock checks which put people at risk of not having enough prescribed medication. We found staff had not been recording the date of opening on liquid controlled drugs, so the effectiveness of these medicines could not be assured. We observed staff administer medication safely, however staff did not have access to the provider’s policy on medication management which meant they did not have access to clear guidance and processes, for example on the storage of controlled drugs, or the management of high blood sugar (hypoglycaemia). Due to the identified shortfalls in the management of medication, we found this to be a breach of regulation for safe care and treatment and managing medicines safely.