Whitestone Lodge

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 inadequate. 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.

The service was previously in breach of the legal regulation in relation to the management of people’s medicines. Improvements were found at this assessment and the service was no longer in breach of this regulation.

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 did not always have a proactive and positive culture of safety based on openness and honesty. For example, lessons learnt following accidents and incidents were not identified to promote good practice. There was a process in place for recording and reporting events such as accidents and incidents, however, there was no formal process in place for analysing accidents and incidents as a way of looking for themes and trends and any lessons learnt to reduce further occurrences.

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. For example, staff worked well and shared relevant information with other professionals such as community district nursing teams, dieticians and speech and language therapists (SALT).

The provider did not always share concerns quickly and appropriately. For example, safeguarding concerns were raised with the local authority, however, CQC were not always notified of allegations of abuse as required. However, staff had completed safeguarding training and were knowledgeable about the different types and indicators of abuse and the procedures for reporting safeguarding concerns.

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. A risk assessment had not always been completed to identify potential risks associated with conditions some people had, such as diabetes and a history of strokes. Care plans for those people did not provide any guidance for staff on or how to recognise and respond to potential complications associated with the conditions.

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. For example, codes were written next to keypad locks fitted to doors leading to areas of the home which were unsafe for people to enter. The keypad lock to a door on a main corridor leading directly onto a set of stairs was broken posing a risk to people should they access the room. We observed 1 person at risk of falls walking along the corridor near to the unlocked door with no staff present in the area, we raised this with the provider and registered manager, and they arranged for the lock to be repaired. However, safety checks were carried out on equipment and utilities at the required intervals and records of them were maintained.

The provider did not make sure staff received effective support, supervision and development. For example, staff were not given the opportunity through formal supervision or appraisal to discuss and review their work, performance, training and development needs. However, there were sufficient qualified, skilled and experienced staff. The staffing rotas showed the right amount of suitably skilled and experience staff were on duty each day and night. Recruitment processes were safe, and staff were provided with the training they needed for their role.

The provider did not always assess or manage the risk of infection. For example, the yellow clinical waste wheelie bin in use and located on the car park at the front of the building, accessible to the public was unlocked. The bin was locked after we raised it with staff. The environment and equipment were clean and hygienic throughout the home.

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. For example, medicines were managed by staff who were suitably trained and competent. Medicines were safely stored, disposed of and administered. Medication administration records (MARs) detailed people’s prescribed medicines and instructions for use, including medicines prescribed to people to be given when required (PRN). MARs indicated people received their medicines at the right times and in the right way.