West Cotes Residential Care 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 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 service was in breach of legal regulations relating to the safe management of medicines.

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. Lessons were learnt to continually identify and embed good practice.

Incidents and care updates were consistently recorded. Monthly analysis was undertaken in relation to falls, accidents, urinary tract infections (UTIs), and pressure areas, enabling trends to be identified and used to inform improvements in care delivery.

Referrals to GPs and other healthcare professionals were made promptly where required, ensuring people received appropriate clinical support. Learning from individual incidents and audits was shared with staff, who were provided with up-to-date information and guidance to support safe, responsive, and effective care delivery.

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.

End-of-life care was in place for one person, with a Gold Standards Framework (GSF) document completed to ensure their wishes and care needs were clearly recorded and followed.

There was effective collaboration with external healthcare professionals, including regular visits from a foot health professional, which supported people’s ongoing wellbeing. Staff maintained good communication and liaison with a range of healthcare services to ensure coordinated and safe care.

Pre-admission processes were established to gather relevant information prior to admission, including from hospitals and other care settings. Comprehensive pre-admission assessments were completed to ensure that people’s needs could be met safely and effectively within the service. There was a clear focus on admitting people with lower-level needs, which supported the stability of the service and helped ensure consistent, quality care delivery.

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 quickly and appropriately.

At the time of the review, there were no Deprivation of Liberty Safeguards (DoLS) in place. Five people were living with dementia and the registered manager believed they were able to make their own decisions. However, no assessments had been completed to establish whether they had the capacity to make the specific decision about living at the home. As there were concerns about some people's ability to make this decision, we could not be confident that their rights had been fully respected.

People’s choices and rights were respected, and where individuals lacked capacity, best interest decisions had been completed to ensure care was delivered lawfully and in line with their preferences.

People told us they felt safe at the home, one person said, “The staff look after me.” Staff demonstrated an awareness of safeguarding risks and were able to describe appropriate reporting procedures. However, it was identified that safeguarding training had not been fully completed, which presented a potential risk in ensuring all staff had up-to-date knowledge and confidence in recognising and responding to concerns.

Some inconsistencies were identified in relation to risk management and oversight. Where weight loss had been identified as a risk, appropriate actions had been taken, including the use of nutritional supplements and GP involvement. However, although weekly weight monitoring had been identified as a requirement, there was no evidence this had been consistently completed, which limited effective evaluation of the interventions in place.

In addition, care planning relating to diabetes was not consistent, with appropriate documentation in place for one person but not for another with similar needs. These issues indicated a need to strengthen consistency in monitoring and care planning across the service.

People were supported to manage risks associated with their care, with evidence of positive outcomes. A family member told us how their loved one was supported with prescription supplements to help them maintain their weight. Additionally, one person’s pressure ulcer had improved, demonstrating effective intervention and ongoing management. Staff understood people's individual risks and used risk assessments to guide the support they provided. This helped keep people safe while encouraging them to be as independent as possible.

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.

Concerns were identified in relation to the environment. The laundry room was small and did not support a clear clean-to-dirty workflow, which increased the risk of cross-contamination. In addition, the walls were in a state of disrepair and were not easily cleanable, limiting effective infection prevention and control.

General areas of the home also required repair and redecoration. This had the potential to impact people’s comfort, dignity, and overall experience of the environment, as well as the provider’s ability to maintain appropriate cleanliness standards.

The home did not have a shower. The registered manager confirmed that people were made aware of this prior to moving into the service. However, the absence of a shower limited choices available to people in relation to personal care and may impact their independence, preferences, and overall wellbeing.

Despite these concerns, appropriate equipment was available to support people’s needs, and servicing records were up to date, providing assurance that equipment was safe and fit for purpose.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

People told us staff were kind and supported them safely. One person said, “The [staff] are phenomenal to me. They have all been caring and kind.” Training compliance was low in key areas, including the Mental Capacity Act 2005 (MCA), Deprivation of Liberty Safeguards (DoLS), and safeguarding. This impacted assurance that staff had the necessary knowledge and understanding to meet people’s legal and safety needs.

Recruitment practices were generally safe; however, interview records did not consistently evidence a robust audit trail of the recruitment process.

Activities were provided on a limited basis, with designated hours across three days per week, reducing overall access for people. The provider's staffing arrangements reduced opportunities for people to engage in meaningful occupation, social interaction, and stimulation, with a potential negative impact on their emotional wellbeing, independence, and overall quality of life.

Staffing levels were determined using a dependency tool and reflected the needs of people living in the service, supporting the safe delivery of care. People told us staff were quick to respond to call bells. One person said, “They come as quickly as they can with the staff they have.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff demonstrated an understanding of infection prevention and control practices and were able to describe measures to reduce the risk of cross-contamination. Staff were confident in the correct use of personal protective equipment (PPE), supporting safe care delivery.

Environmental cleaning systems were in place, including fortnightly deep cleaning of bedrooms and regular mattress audits. These measures supported the maintenance of hygiene standards and reduced the risk of infection transmission.

A recent outbreak had been managed effectively, indicating appropriate implementation of infection control procedures and oversight to protect people and staff.

The provider did not always make sure that medicines and treatments were safe. Medicines management did not always meet people’s needs. People’s abilities to make decisions about their medicines and how they preferred to take their medicines were not always respected. . Staff did not always involve people in planning.

Medicines management was not always safe. Staff did not consistently store controlled drugs securely or follow all legal requirements. The service had recently changed its returns process, but this was not yet used consistently and was being developed further. Records were not always accurate or complete, including allergy information and medicines documentation.

Care plans did not always support safe medicines use. They lacked clear, personalised guidance for staff, and some plans did not cover specific or higher-risk medicines, including those needing regular monitoring such as diabetes medicines.

Protocols for medicines prescribed on a when required basis (PRN), and guidance for variable dose medicines, were not always available to support staff in administering medicines safely and consistently. Staff did not always record reasons for omitted or refused medicines or escalate concerns in line with policy.

Staff had systems in place to support safe medicines management, and some areas were well managed. Medicines were stored securely in most areas, and staff followed clear processes for ordering, receiving and recording medicines. Staff completed training and competency checks, and audits and incident reviews supported learning and improvement. Records for topical medicines and transdermal patches were in place and completed.