Wellfield Also known as Wellfield Pines and Wellfield Acorn

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

We found some improvements at Wellfield since the last inspection with regards to a safe service being delivered. A developing learning culture was evident compared to the previous inspections, including staff access to improved training opportunities, and leaders benefitting from oversight of staff competencies. We also saw effective and safe staffing arrangements, with future staffing models factored in by leaders which was an improvement from previous inspections. Although there were no children resident at the time of our inspection, the environment we assessed was noted to be an appropriate space, with considerations for future residents’ safety being evident.

However, safe care in other areas was inconsistent, and improvements made from the previous inspections were limited. For example, there was a lack of assurance around the oversight and governance for PRN medications, resulting in the potential for future harm. We also identified concerns around care pathways and transitions, leading to dissatisfaction from stakeholders and other agencies.

Although we found leaders at Wellfield to have some identification and mitigation processes in place these were not applied consistently, including on one occasion which resulted in significant harm to a child. This was therefore considered a breach of regulations .

You can find more details of our concerns in the evidence category findings below.

We will be following up on our concerns to ensure they have been put right by the provider.

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.

There was a developing culture of safety and learning at Wellfield. This was based on openness, transparency and learning from events that had either put people and staff at risk of harm, or that had caused them harm. Staff spoke positively about the learning culture now in place at the home.

Overall, lessons were learned from safety incidents, resulting in changes that improved care for others. ‘Before, during and after’ folders had been used effectively to assess and learn from incidents, and meetings with staff held to disseminate this information. We found evidence of some risk assessments being amended in response to incidents, although this was not always effective and on one occasion resulted in significant harm to a child.

During our assessment we found that all notifiable incidents had been appropriately reported and relevant agencies were informed, with improved processes since the previous inspection.

There were opportunities for reflection as noted on the staff training and development offer.

We were unable to speak directly to a child who was no longer resident at the home. Relevant agencies had informed us that the provider had not been transparent to the child about their placement ending. We were unable to ascertain how the child felt about this information.

The provider had worked creatively and supportively to ensure that the young person had familiar staff with them during the most intensive period of crises.

However, staff members and stakeholders expressed their concern at how this young persons transition to another service was communicated to them, and that the young person would not be returning to Wellfield. We noted some concerns in relation to Duty of Candour from leaders in how the child’s placement ended following their acute admission, and we recommend as a priority that this is reviewed by the provider.

During our assessment of the home we were unable to speak with children who had been resident there recently. However, in records examined, we noted limited compliance with risk management plans and processes which had led to an incident of significant harm to the same child, although records examined did not clearly demonstrate the personal experiences of the child following the incident.

Staff we spoke with demonstrated an understanding of safeguarding vulnerable children and how to take appropriate action if required. Staff were supported to understand safeguarding, what being safe meant to them, and how to raise concerns. Although most staff spoke highly of the safeguarding training offer, some told us they wanted more opportunity for constructive supervision sessions rather than during management appraisal.

There was access to appropriate safeguarding training which had been completed by staff at all levels. There was time provided during team meetings and within regular appraisals for staff to discuss safeguarding matters.

Although there was evidence of some positive safeguarding practice , the processes and practices in regards to risk mitigation were not consistently implemented or effective in ensuring that children were protected from avoidable harm . We recommend as a priority that this is reviewed by the provider, prior to new children being admitted.

At the time of our assessment, we were unable to speak to recent child residents directly. However, we noted a significant incident where harm was caused to a child despite the specific risk having been identified. We were unable to ascertain the child’s views on this specific incident.

Staff told us that overall, incidents were generally managed well and crisis protocols were put in place where required, with new action plans or risk assessments provided. Where there is evidence of escalating risk, staff noted that emergency risk assessments were mostly undertaken.

We found significant concerns in relation to a risk management plan being ineffective. For one concerning incident, when a significant risk was identified by both staff and the child, the risk management plan devised was not effective enough to protect the child from harm, despite care plans noting continuous supportive observation by staff. In addition, the devised plan was not implemented effectively, and an event resulting in significant physical harm to the child and several episodes of restraint occurred. Sufficient and effective action was not taken by leaders and staff to mitigate this foreseeable and preventable risk.

Wellfield was found to have some risk assessment, identification and mitigation processes in place, which was an improvement from previous inspections. However, this was not consistently implemented, and it was unclear if staff understood the identified risks. Risk assessment plans such as in relation to the previously mentioned incident, did not reflect foreseeable risks that may need restriction, and therefore were not mitigated effectively.

Due to the significant harm caused to a young person as a result of inadequate and ineffective risk assessment and management in relation to this incident, the provider is in breach of Regulation 12 ‘safe care and treatment’ of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There were effective arrangements to monitor the safety and upkeep of the premises. An independent fire risk assessment had been undertaken recently and suggestions made had been acted upon. Leaders and staff considered how environments could keep children safe from psychological harm as well as physical harm.

At Wellfield, even though at the time of our assessment there were no children resident there, the environments available for their use were designed to meet children’s needs and help keep them safe. Risks to children had been considered and, where necessary, adaptations made. Access to staff rooms were via lockable doors and accessible kitchen areas contained only basic cooking accessories that could be added to when risks to children were noted to have reduced. Garden areas were seen to be clean, appropriately secure and bright. A lockable ‘Control of Substances Hazardous to Health’ (COSHH) storage area was seen to be neat and tidy with instructions for the safe use of cleaning products provided for staff use.

At the time of our assessment, having reviewed relevant documentation and in discussion with staff members, we were assured that risk assessment processes would be used to ensure that staffing levels at the home would appropriately meet the specific needs of children living there.

Management teams had oversight of any learning gaps for staff, and they could facilitate additional training as required. We were made aware that future staffing and recruitment would be given due consideration prior to any future admissions to the home, always ensuring that there were enough appropriately trained staff in place to meet the needs of children in their care.

Staff at all levels had opportunities to learn. This included supervision, appraisal and support for all staff including managers and leaders. The training offer was stronger than seen in previous inspections. Staff received training appropriate and relevant to their role including recent access to learning disability and autism training, delivered in-house by an accredited trainer. We also saw that staff benefited from training regarding appropriate behaviour and communication.

There were safe recruitment practices to make sure that all staff were suitably experienced, competent and able to carry out their role, including within the leadership team. Processes were in place that included monthly appraisals to ensure staff’s learning needs were met. Managers sought and accessed external professional supervision where required.

Staff were aware of the infection control policy and where to find it.

The environment was observed to be clean and tidy, with appropriate infection control measures in place that included measures to take in the disposal of food waste and keeping kitchen and food preparation areas clean to help reduce the risk of infection.

There was an effective approach to assessing and managing the risk of infection, including utilising individualised risk assessments.

Consideration had been given to a child’s use of PRN medication at Wellfield, and supporting their autonomy in requesting it. This was an improvement from inspections where children previously resident were noted to have been prompted to take PRN medications. However, we observed unclear indications for PRN medication on their care plan including the maximum dose in 24 hours, recommended spacing between doses, and what to do if PRN is requested regularly by the child.

Staff informed us that there had been training sessions regarding the use of PRN medication for the child who was no longer resident at the home, and that they understood when to administer PRN medications and what the maximum dose was. However, because of the lack of clarity in care plans and where to find this information, we were not assured where the information was accessible at the time of administration, or the processes in place for future residents.

We recommend as a priority that this is reviewed by the provider, prior to new service-users being admitted. Leaders acknowledged this during the assessment and are committed to improving this.

On examination of medicine administration records for a child no longer resident at the home, we were not assured that that due care and consideration had been given to the safe administration of PRN medication. There were 2 incidents where a service user had been administered PRN medication without consideration for spacing with regular doses.

The approach to PRN medicines did not reflect current and relevant best practice and professional guidance. There was no reference to PRN medication in the providers medicines policy.