Wisden 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

During our assessment of this key question, we found concerns around the recording and reporting of unexplained injuries. From our review of wounds and associated records, followed by an analysis completed by the provider, 7 unexplained injuries were identified that had not been accurately recorded or reported. Investigations into the cause of these had not been completed and therefore placed people at further risk of injury and harm. This was a breach of regulation. You can find more details of our concerns in the evidence category findings below. Risk assessments were routinely completed and reviewed for all aspects of people’s care. Where we observed people receiving care which was not in line with their assessed needs, the registered manager took immediate action once informed. Staffing levels were assessed. We saw sufficient staff on duty, and that people’s needs were met in a timely manner. Robust recruitment practices were followed, and staff received a range of training. There were systems in place to share learning from events that occurred at the service such as complaints, concerns or incidents. The environment was safe and equipment was routinely serviced and maintained. Infection prevention and control measures were in place and alongside an up-to-date policy and guidance. People received their medicines in accordance with the prescriber’s instructions and there were checks in place to ensure that the management of medicines was safe at the service.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People felt they could speak up. They shared with us they had no concerns for their safety. One person said, “I’m not sure who the manager is but I’d know her if I saw her. I have no worries, I could and would speak up if I was worried.”

Staff told us the openness and sharing of information had improved. A staff member said, “Manager and deputy come round every day and check on things, let you know of a complaint or anything, (they) speak to you directly.” As a result, they felt the standards in the home had improved.

The provider had a system in place to review and analyse any accidents, incidents or untoward events at the service with a view to lessons being learnt. Whilst staff told us that openness and sharing of information had improved, this was not consistently evident from documentation provided during this assessment.

People felt the service was equipped to meet their needs. They told us that they were involved in assessments and discussions with other services such as the GP and visiting health professionals.

Staff told us assessments and reviews were carried out. We saw admission assessments within care plans, along with regular reviews of planned care.

Feedback received from partner agencies was positive. They told us that staff and management engaged well with their services and that focus was always on people and their experiences.

The provider had a system in place to ensure that they worked alongside partner agencies in the delivery of care and support. Multi-disciplinary meetings were regularly held at the service. We saw that the discussions held were reflected in people’s care plans and action was taken where needed. However, improvements were needed to ensure the outcomes were effectively communicated to the wider staff team.

People told us they felt safe living at the service. One person said, “I feel safe, I’m not worried about anything.”

Staff told us they knew how to respond to any concerns about people’s safety and allegations of abuse. One staff member said, “I would report concerns to Hertfordshire council, I know where the contact info is.” They confirmed they had received training and knew where they could access information about safeguarding. Feedback from staff and leaders about potential safeguarding events at the service was, initially, inaccurate. Once further checks and an analysis was completed, they were able to confirm our findings regarding unexplained injuries and ensure action was taken.

We observed a person who had a skin tear on their wrist and a bruise on their shin. This was a person who was dependent on staff for all transfers and aspects of their care. We reviewed their care plan, daily notes and the safeguarding log and found no corresponding entries to the injuries seen. We were also unable to establish any cause or reason for the injuries within incident and accident records. Due to this concern, we reviewed records for the months of February, March and April 2024. We found 12 bruises and 6 skin tears recorded on an injury chart which did not correspond with falls or incident/accident records. There was no reason or explanation for the injuries on the charts we looked at, nor within people’s individual records.

The provider had a system in place to report safeguarding concerns however this was not being operated effectively at the service. A safeguarding log was maintained, however as described in our observations, we found examples where unexplained injuries were not consistently recorded or subsequently reported. We raised this concern with the registered manager during feedback. They were unable to provide immediate assurances but confirmed they would complete an analysis of wounds. The provider shared the outcome of this analysis and confirmed that 7 unexplained injuries had occurred that had not been accurately recorded. They completed safeguarding referrals to the local authority for these retrospectively, along with statutory notifications to CQC. This meant that people had sustained unexplained injuries which had not been investigated.

People told us staff were kind and they supported them well. They told us they received their care safely. One person said, “Staff are great, all kind.” However, some people were unable to explain to us how they were involved in managing risks or share ways in which staff supported them to manage potential risks to their health, safety and wellbeing.

Most staff were able to explain people’s individual risks and how they needed to be supported. However, for some staff, when asked about risk management their responses were inconsistent. When asked about risk management one staff member said, “Safeguarding concerns we report to CQC, police or council, I know where to find contact info. I’ve been part of a fire drill and there is weekly alarm testing.”

Staff were gentle in their approach. However, we observed that not all staff were confident or skilled in responding to people when they were expressing agitation or behaviour that may cause concern to others. We also noted that not all people received pressure relieving care in accordance with their care plan. We raised this with the management team for their action. During an observation, we saw that one person identified as being at risk when eating, did not have a food that had been modified to the food texture they needed or consistent supervision. The registered manager addressed this immediately and assured us training was in place.

The registered manager had a system in place to record risks to people were identified and shared. They maintained a matrix which identified at a glance where risks were present for people. Risk assessments were routinely completed and reviewed for all aspects of people’s care. However, improvements were needed to ensure that known risks were effectively communicated to the wider staff team and action was consistently taken.

People felt safe in the home. People were able to move around the home freely and had access to equipment they needed. Call bells were accessible, however one person told us their call bell did not always work. We raised this with the registered manager to carry out monitoring since it had recently been repaired. During feedback, the registered manager confirmed that all call bells had been reset and monitoring remained ongoing.

Staff confirmed they felt safe working at the service and had the equipment they needed. Staff told us they had taken part in a fire drill and training was up to date.

The environment was well maintained, and no hazards were identified. Where equipment was present, we saw this was in good condition. Fire safety equipment was in place, along with clear signage.

The provider had an effective system in place to ensure that equipment and facilities were routinely serviced and maintained. However, we noted at the start of our assessment, that some safety certificates had recently expired or were close to expiring. The registered manager provided verbal assurances that these had been completed by the end of the assessment process. Regular audits were completed, with action taken when identified as needed.

People told us staff supported them when needed. A person said, “They are here if I need them.”

Staff told us they felt there were enough of them to meet people’s needs in a timely way. One staff member said, “There is enough staff, it is better now.”

We saw people were supported when needed. Call bells were answered promptly and people were not left waiting for care. Staff were a visible presence throughout the service.

Staff recruitment was safe and all essential pre-employment checks were completed prior to a staff member starting work. The registered manager used a dependency tool to determine staffing levels. We saw rotas in place which matched the assessed level of staff. There were consistent checks on the responsiveness of staff to call bells, with feedback provided on each occasion. Systems were in place to ensure staff received the training, support and supervision needed for their roles.

People had their own space which was kept clean and tidy. People had no concerns when asked about hygiene or IPC.

Staff were able to explain good IPC practice. They confirmed they had received training and felt confident in their practices.

Staff were observed to be working in accordance with IPC guidance in most cases. However, we did observe some staff members putting on blue gloves to assist people to transfer or mobilise. When asked, staff were not sure why they had chosen to do this. We raised this with the management team who confirmed they would remind staff of good practice. The environment was clean and housekeeping staff were moving methodically around the service completing tasks on the day of our visit.

IPC audits were completed regularly. The provider had an up-to-date IPC policy in place. There was guidance in place for all staff in relation to the management of infection and the action they should take should an outbreak occur. Infection prevention and PPE was a standard agenda item for discussion at team meetings.

People told us they received their medicines as needed.

Staff were able to demonstrate safe practice and understanding around the management of medicines. They confirmed they had received training and competency checks.

Medication records showed that medicines were administered in accordance with the prescriber’s instructions. Quantities checked were correct. Antipsychotic medicines were reviewed. People’s preferences as to how they wished to be supported with the management and administration of their medicines was included in care plans. There were regular audits of medicines and associated records.