Waverley 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. Following this assessment, we have rated safe as inadequate. We reviewed 8 quality statements and identified six breaches of the legal regulations. The breaches included the management of safe care and treatment, dignity and respect, meeting nutritional and hydration needs, premises and equipment, good governance, and staffing. Safety risks to people were not managed well. Staff did not have clear written guidance or training on how to support people safely. Staff did not always monitor people’s health conditions or care provided to ensure it was in line with people’s identified needs. Risk assessments were incomplete and did not include risks we identified during our assessment. Medicines were not always well managed. The processes and systems in place to manage potential risk of harm to people were not always effective. The premises had not been effectively adapted to meet people’s needs and timely action in response to environmental shortfalls was not always taken. Recruitment records evidenced staff were not always robustly recruited.

This service scored 28 (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 limited feedback from people regarding learning culture, however our observations identified ongoing concerns since the last inspection. The culture of the service had not improved and concerns about safety had not been acted upon or lessons learned to embed good practice. People were not receiving the standard of care described in the quality statement. People’s needs are not met.

Staff told us they felt listened to and could raise any concerns; however, the manager was unable to share with us examples of lessons learnt. The manager and provider were not open and honest with staff about the improvements needed within the service since the last inspection.

The providers systems and processes did not promote a culture of safety based on openness and honesty. Records were not maintained detailing accidents and incident that occurred at the service and there no evidence of lessons learnt. For example, a person sustained an injury which required medical attention, however there was no record of the incident or any evidence to show what action had been taken to mitigate future risk.

We received limited feedback from people with regards to safe systems, pathways and transitions. However, our review of peoples care records evidenced inconsistencies and a lack of evidence to ensure people received safe and consistent care. The approach to identifying and managing risks for people was not proactive and effective, and placed people at risk of harm from a lack of risk assessment and care planning. People were not receiving the standard of care described in the quality statement. People’s needs were not being met.

The manager did not promote safe, systems, pathways and transitions. They lacked knowledge and understanding around people’s care needs and of any referrals made on their behalf to other professionals.

Partner organisations reflected ongoing improvements where needed to the service and an action plan was in place with the Local Authority. Progress of the action plan was not evidenced as the Manager confirmed all actions remained ongoing. There was a lack of coordination and priority with regards to the plan and the manager could not evidence what improvements to date had been made.

There was a lack of processes in place to ensure people received safe and effective care. For example, a person using the service sustained a head injury from an incident within their bedroom, there was no incident report to reflect what had happened or what actions/observations were completed following the injury.

We received limited feedback from people with regards to safeguarding. However, one person told us, “I feel safe. I feel able to speak with staff, I have family at home who I can speak with.”

Staff provided different responses to safeguarding. One staff member stated, “Not sure where the safeguarding policies are kept.” Whereas other staff knew how to access them. Through discussions with the manager, they lacked knowledge and understanding about their role and responsibilities for keeping people safe from the risk of abuse. They confirmed they did not maintain safeguarding records and lacked oversight of safeguarding incidents that occurred at the service.

We observed staff treating people well. However, the safety concerns we observed throughout the environment and with equipment placed people at risk of harm. When we raised the concerns at the time with the manager, they failed to take immediate action to mitigate the risks.

There was a lack of records to show appropriate action had been taken to investigate and protect people from harm. The provider had not always followed safeguarding procedures to protect people from abuse and the risk of abuse. They failed to refer incidents of a safeguarding nature onto the local authority, including an incident when a person sustained a head injury.

We received limited feedback from people with regards to managing risks. However, our review of peoples care records evidenced inconsistencies with regards to the management of risk and a lack of evidence to ensure people received safe and consistent care. Observations completed during the assessment evidenced a failure to ensure risk was identified and mitigated. People were not receiving the standard of care described in the quality statement. People’s needs were not being met.

Nursing and care staff spoken with were not always able to give competent answers relating to involving people in their care and managing risk. Care plans did not always provide sufficient guidance for staff on how to care for people safely.

We observed faulty bedrails to a person’s bed placing them at risk of falling from the bed. The fault was logged by staff in the maintenance book some weeks prior to our site visit. No action had been taken by management to ensure the fault was rectified, placing the person at risk of avoidable harm. On the second day of the assessment the person had moved to a new bedroom with new bedrails that were working, however, we saw the air flow mattress monitor on the bed was flashing indicating it was faulty. The door to the new bedroom had recently been changed to an approved fire door however, there were no handles fitted to either side of the door preventing easy entry or exit. This placed the person at risk of entrapment in the event of an emergency such as a fire breakout.

People were placed at risk of avoidable harm due to the lack of risk management. No risk assessment had been completed to guide staff on how to minimise the risk of harm to a person who smoked and was prescribed emollient creams. There was a lack of oversight with regards to people’s weights. Care plans stated some people’s weights were to be recorded weekly however, there were no records to evidence the monitoring of people’s weight. This placed people at risk of malnutrition and other health complications. The provider had a process in place for staff to follow for reporting health and safety concerns. However, on review of this process we found multiple recordings detailing faulty equipment, including the faulty bedrails and broken bedroom furniture that had not been actioned. The provider failed to ensure to manage risk and failed to adopt effective control measures to mitigate risk.

We received limited feedback from people with regards to safe environments. However, one person told us they did not have access to a call bell. Our observations identified significant safety concerns throughout the environment and with equipment. Inspectors observed a lack of accessible call bells available for other people.

Staff explained the practices they followed to ensure the environment and equipment was safe and confirmed they reported any issues to the manager. However, the manager told us they were unaware of the safety concerns we identified during the inspection.

The environment both inside and outside was observed to be unsafe. Fire doors across the home were overall unsafe. For example, many did not fit tightly into the recess on closing and others were not fitted with fire protection door strips making them ineffective in the event of a fire. There were no door handles on either side of one person’s bedroom door to enable access or exit from the room. The laundry room contained a range of hazards and was secured by a keypad lock for staff use only, however the code to the keypad lock was clearly displayed on the outside of the door. Floor coverings in communal areas including stairs, corridors and outside paving were damaged increasing the risk of slips trips and falls.

There was a lack of processes in place to check on the safety of the environment and equipment. The manager told us they had completed daily environmental checks; however, they had not maintained a record of their checks and findings. In addition, the manager was unaware of the environmental safety concerns inspectors identified throughout both site visit days.

People told us there were enough staff available to support people. One person told us, “There are enough staff that help me, even when its busy.”

Staff spoken with told us there were enough staff on duty to enable them to meet people’s needs. Staff comments included, “We have enough staff at present” and “Staffing will increase if residents needs change.” Nursing staff told us they lacked clinical oversight and competency assessments.

During our assessment, we had no concerns about staffing levels. Staff were observed to attend to people's needs promptly.

There were ineffective systems and processes to ensure the safe recruitment and training of staff. Gaps were identified within staffing files, for example there was no evidence of staff qualifications and references being sought from the staff members previous employer. The training matrix highlighted gaps with mandatory training and specialist training. Clinical staff were not provided with the training for their role. There was a lack of evidence of supervision to show all staff received this regularly.

We received limited feedback from people regarding infection, prevention and control.

Staff confirmed there were adequate supplies of PPE. However, we observed a lack of PPE during the site visit. Discussions with the manager showed they lacked oversight and understanding with regards to IPC.

We observed a range of concerns which increased the risk of the spread of infection. We saw items of dirty equipment, fixtures and fittings including stains and spillages on a mat in one person’s bedroom and heavily stained carpets on stairs and landings. The walls, floor and ceiling in the food storeroom was covered in black damp stains. Food items and prescribed food supplements were stored on shelving and on the floor in the food storeroom. We observed empty hand gel and paper towel dispensers in some bathrooms and bedrooms. Laundry facilities were inadequate to ensure effective laundering of people’s belongings. The room itself identified a range of hazards to staff working in this area and the process for laundering exposed a risk of cross contamination.

Staff had received training in infection prevention and control. There was a lack of processes in place to manage the risk of infection. There were no cleaning schedules to monitor the cleanliness' and hygiene of the environment and equipment. People and staff did not always have access to the required personal protective equipment (PPE).

We received limited feedback from people regarding medicines optimisation. However, our observations showed unsafe practices. For example, people did not always receive PRN (medicine to be administered as needed) medicines safely or in line with good practice guidance.

Staff told us they were supported by healthcare professionals who reviewed people’s medicines regularly. There was no evidence to show staff were trained and competent to manage medicines, or for non-clinical staff who were completing checks of controlled medicines. A nurse told us they had not completed the required clinical training or underwent an assessment of their clinical competence. They told us the manager was not suitably qualified to undertake clinical assessments. However, the provider had not sourced a suitable qualified person to undertake this task.

The provider did not have safe systems for appropriate and safe handling of medicines. Medicines audits had been completed; however, they were not sufficient to pick up issues found during the assessment. Medicine administration records (MARs) did not contain information that assured us medicines were administered as prescribed. For one person prescribed their medicine on alternate days we found this had not been signed for to indicate this. MARs for topical preparations such as creams were not always completed accurately, and we could not be assured people were having them applied correctly. For medicines administered via an enteral feeding tube there was not always information available that supported staff to do this in a safe way. The provider was monitoring the areas where medicines were stored. However, we found when the temperature was outside of the recommended range staff did not always take action to remedy this. Staff were not always recording when thickened fluids were being given to people at risk of choking and aspiration so we could not be assured these were being managed safely.