Walton Manor Residential and Nursing 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 people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. 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 people could be harmed.

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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Staff told us they felt more confident to speak up and ‘mistakes are no longer brushed under the carpet’ but instead seen as ‘something to learn from’. Leaders described an open approach to learning, where ‘we reflect, not blame’ and shared examples of recent safeguarding incidents that led to changes in practice. Relatives told us when issues were raised, such as concerns over staffing, these were ‘dealt with well’ and ‘acted on quickly’. Staff described a recent shift in the culture where ‘you’re encouraged to be honest’, and told us, “We learn from feedback now, even from complaints.”  

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 make sure there was continuity of care, including when people moved between different services. However, relatives reported mixed experiences. One relative said, “They always inform us and make arrangements quickly.” Another relative told us, “[Name] always gets seen when needed. The coordination is good.” However, several concerns were raised about delays in accessing healthcare. Some relatives noted gaps in following hospital or health advice, which led them to feel they needed to supplement care or follow-up themselves. Comments included, “The hospital’s advice is not followed, and staff need reminding,” “I don’t think the care is always well coordinated and we’re not always included or kept informed about what’s happening” and “[Name] hasn’t been supported to attend appointments or go to hospital.”  This mixed feedback indicated gaps in communication. We saw examples of documented care plans being shared with external professionals and recorded evidence of guidance external health care professionals had provided staff to follow.

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 management team confirmed a commitment to continuous safeguarding training and robust incident reporting. Procedures were in place to identify and address safeguarding issues, enabling timely action. The provider shared concerns quickly and appropriately. Staff were trained annually in safeguarding, and demonstrated a strong understanding of types of abuse, reporting procedures, and documentation. Staff showed confidence in identifying and responding to safeguarding concerns and understood the importance of protecting people from neglect and harm. One member of staff told us, “If we see something wrong, we report it straight away.” There was clear knowledge of how to escalate concerns internally and externally. People we spoke with expressed feeling safe. One person told us, “I feel very safe here.” Most relatives consistently reported their loved ones were safe, well cared for, and effective safety measures were in place. One relative said, “There was an issue once, but the manager handled it well and kept me informed.”  

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. Several inconsistencies in documentation meant known risks were not always clearly addressed or updated. We identified errors and outdated information in assessments, such as incorrect personal details and mismatched diet plans. For example, a person had known malnutrition risk, yet weight monitoring was inconsistently documented despite being listed as weekly. We received mixed feedback from relatives on how risks were managed. One relative told us, “They manage risks well, but I wish communication was clearer.” Other comments included, “No I don’t think they involve [Name]. I think they just leave them,” and “[Name]’s involvement in assessments and support is limited and only to a certain extent.” The provider was in the process of developing easier-to-understand care plans and training staff to engage people more actively.   Risk assessments were generally thorough, but communication about these risks with some people was limited, reducing their involvement in decision-making. Staff and leaders told us they focused on balancing risk with respect for people's rights and preferences. One staff member said, “We don't just stop someone from doing something because there's a risk.” We look at how to do it safely instead.”  Staff showed understanding of personalised risk management and described efforts to include people and their families in care planning. Staff feedback highlighted confidence in applying person-centred approaches and adapting care to people’s changing needs.

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. We found evidence of unsafe practices. Several environmental concerns were observed that could impact the safety and well-being of people. These included signs of rust, bodily fluids, and dirt around communal toilets, as well as damaged furniture, and flooring in both people’s bedrooms and communal areas. Damp was evident on a ceiling in one person’s room. People’s rooms were inconsistently maintained. We asked family members if they felt their relative was supported to live in a safe environment. The feedback we received was mixed. Some relatives felt the environment was safe, however, others raised concerns. One relative answered, “Sometimes.” Another relative said, “It’s always welcoming when I visit, but some small repairs have been slow.” One relative reported a broken cabinet door on the floor which had not been addressed for years and other relatives told us about dirty bedding or missing pillows. We identified trip hazards such as trailing wires in communal areas, slip hazards including urine on bathroom floors, exposed wires, and uneven flooring in one communal area. These risks had not been picked up or addressed through regular safety audits. Items such as scissors and hazardous substances were left out in communal areas where they should be securely stored. Staff had left sugary drinks unattended in these shared spaces creating a risk to people with health conditions that require dietary control. In one person’s bedroom, visible rust was observed on the floor, alongside a dirty pressure monitor. Confidentiality breaches were noted, with care files left in public areas or the wrong rooms. While there were regular audits, repeated findings, for example, broken furniture and documentation left unsecured, suggest these were not effectively actioned. The provider was in breach of legal regulations in relation to Regulation 12 of the Health and Social Care Act 2014 Safe care and treatment. The management team were responsive to our feedback and told us they had scheduled regular maintenance checks and would enhance staff awareness about confidentiality.

The provider made sure 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 were up to date with mandatory training. One staff member told us, “I feel valued here, and training helps me do my job better.” Supervisions, appraisals, and team meetings were held regularly. Staffing levels appeared sufficient for basic care, with improvements noted recently in morale and responsiveness. However, some staff told us they felt they sometimes did not have enough time to spend with people as they were busy with other tasks. Leaders told us they were actively recruiting more staff and focusing on skill development to improve care quality. People described staff as kind and caring, and relatives praised their dedication. One person said, “The staff here are lovely and patient with me.” Comments from relatives included, “The staff seem to know what they are doing” and “We see staff go on training.” Some relatives raised concerns about the consistency of management. One relative said, “Management does have a high turnover, however, there are quite consistent staff.”  We found the provider has maintained leadership continuity despite challenges. These arrangements reflected efforts to sustain oversight and support during a period of change. The return of a familiar home manager and the presence of an experienced deputy manager contributed positively to ongoing leadership stability.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. We observed PPE was disposed of inappropriately, including in general waste bins located in both communal and bedroom areas. PPE was left out in peoples’ rooms. We found pillowcases were visibly soiled with bodily fluids. One relative told us, “[Name]’s pillow is always dirty.” We observed communal areas were mostly clean and tidy. Feedback from relatives was mixed. One relative told us, “The home is clean, and staff are careful about hygiene.” Another relative described the home as, “Spotless.” However, other comments included, “Sometimes the room isn’t as clean as I’d expect,” “Toilets are dirty and need cleaning. I have to clean it,” “The communal areas look to be clean, but [Name]’s bedroom is very dirty” and “Staff respond well when we raise concerns, but the room cleanliness is sometimes overlooked.” We observed some people had visibly dirty nails, and toothbrushes were not replaced per policy. Personal care items such as hairbrushes and nail brushes were observed left in shared areas rather than stored individually. We observed food waste was left in inappropriate locations, raising infection and dignity concerns. Staff demonstrated awareness of infection control procedures, including PPE use and outbreak response. Staff stated they were up to date with Infection Prevention Control (IPC) training and knew how to escalate concerns. One staff member said, “We are trained to use PPE properly and stop infections spreading.” We were not assured the service was supporting people to minimise the spread of infection. The provider was in breach of legal regulations in relation to Regulation 12 of the Health and Social Care Act 2014 Safe care and treatment.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. We observed issues in medication management, including errors in record-keeping, unsafe storage and a lack of proper PRN protocols (PRN protocols are clear instructions for giving medication only when it's needed, not on a regular schedule). The treatment room was observed unlocked and unattended, raising security and safety concerns. We identified medication storage concerns, such as unsecured fridges, disorganised storage areas, and a persons prescribed cream found in someone else’s room. Important instructions for ‘when required’ medicines were missing or unclear, which could affect how safely and effectively these medicines were given. Medicines audits were in place and staff had undertaken medicines training. People who were able to self-manage medication were supported appropriately, and staff described their role in administering, recording, and escalating concerns. One staff member told us, “We follow protocols carefully to keep people safe.” The provider was in breach of legal regulations in relation to Regulation 12 of the Health and Social Care Act 2014 Safe care and treatment. We were not assured medication was being managed and administered safely.