Wasdale Court

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

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 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 that 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 positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and reported safety events. De-briefs were held following incidents to consider any learning. This ensured appropriate action was taken and to check the well-being of those involved. The provider monitored accidents and incidents to identify any potential themes or trends. Further development was required to demonstrate how this information was used to improve practice and potentially reduce further incidents.

Details of accidents and incidents were shared appropriately with partner agencies and their advice sought. When issues about staff practice arose, this was addressed.

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. Information was available to support people needing to access health care facilities. The management and staff team worked closely with other professionals to aid the transition between services.

The provider did not always work well with people 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.

The restrictions in place for people, such as reducing access to certain items and furnishings, had not been regularly reviewed to ensure they were necessary and consider ways to further reduce these. Staff knowledge around what restrictions were was not consistent and required further development. The provider had recently started completing mental capacity assessments and associated best interest decisions for additional restrictions so these could be reviewed moving forward. The registered manager had a process to monitor applications to deprive people of their liberty.

Staff understood the importance of supporting people to live free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff completed safeguarding training and were aware of the different types of abuse. The provider shared concerns quickly and appropriately and had a safeguarding policy in line with the relevant legislation.

The provider did not always work 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.

A professional noted, “I don’t see active care planning and support in place: it still feels at the level of reactive support rather than proactive support.” People’s records did not always demonstrate they were consistently included in discussions about potential risks, solutions to help mitigate these or to empower people to take positive risks. Whilst risk assessments were in place, these did not always clearly guide staff about the actions needed to help reduce risks for people. This meant staff practice was inconsistent with managing some risks including supporting with personal care and appropriate diet.

Detailed information was in place to support people who experienced behaviour which may challenge the service, and staff were confident in their approach. However, not all staff had completed training in this area and the provider was not clear about their training expectations.

The provider employed a professional specialising in positive behaviour support who was involved in discussions about approaches to people’s care. Specialist training had re-commenced shortly prior to our assessment.

The provider did not always detect and mitigate potential risks in the care environment. They did not always make sure the facilities supported the safe delivery of care.

Systems and processes to monitor the environment had not always identified areas of the service that needed improvement and repair. This included the poor condition of one person’s bathroom, missing window restrictors and unsafe storage of cleaning products. Communal areas were not always inviting for people. Where actions had been identified, the provider had not consistently ensured these were completed in a timely manner. For example, we observed a broken window in a communal area which had originally been reported in March 2025 and not been replaced. Fire doors also identified for replacement in November 2024 and were still waiting to be changed These was highlighted to the management team and actions commenced during our assessment. A fire risk assessment had recently been completed, and the actions were in the process of been addressed. Whilst most fire safety checks had been completed, there were some outstanding including door closures and emergency lighting. Records for fire drills did not contain all the relevant information to aid staff learning and further development was required around fire evacuation procedures to ensure everybody could be evacuated safely. This was discussed with the provider who also started to address this during the assessment.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective development.

Staff had not consistently completed training tailored to people’s individual needs including practical manual handling and detailed mental health training. The provider did not have sufficient oversight of training. Some training had been delivered during our assessment and further training arranged. Staff told us they could request further training if needed.

Changes to the staffing team had affected the continuity of care people received. Lots of staff left when the ownership of the service changed. We received comments about the impact of the changes which included, “There were a lot of staff changes; it was poorly handled, and a lot of staff left and this impacted [person’s name]” and "People lost the familiarity." New staff had been recruited, and agency staff supported safe staffing numbers, particularly at night-time. However, some people who used the service found this difficult. The provider acknowledged that developing staffing was a key area for the service to address.

Staff were recruited safely and received inductions. Staff received effective supervisions, and appraisals.

The provider did not always assess or manage the risk of infection and issues of cleanliness had not been consistently addressed. Parts of the service were not clean including some ensuite bathrooms, a communal toilet and kitchenette. Other parts of the service were worn, such as a rusty radiator and broken radiator cover which would not support effective cleaning.

Records did not demonstrate people had receive consistent support to maintain good personal hygiene. For example, we reviewed one person’s records and there was no evidence they had received support with their oral care.

Staff had completed infection prevention and control training and had access to PPE.

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

There were processes in place to ensure the safe and effective use of medicines. People were given their medicines safely and in a timely manner. Medicines were stored safely. Individual risk assessments were in place when needed and people’s individual preferences for medicines administration were clearly recorded. Detailed guidance specific to each person guided staff with how to administer medicines prescribed as and when needed. Records showed that management or staff carried out regular medicine’s audits. There was a process in place to record any medicines related errors. Staff had received medicines handling training, and their competencies were assessed regularly to make sure they had the necessary skills.