Weymouth Manor

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 a breach of the legal regulation in relation to the safe care and treatment of people. Assessments to identify risks to people’s health, safety and welfare were not always robust and this had led to staff not being instructed on how to keep people safe. Lessons were not always learned and shared when things went wrong to drive improvements and maintain the quality of care to people living in the home. Medicines had not always been managed safely and people had not always received medicines they were prescribed to have ‘as required’. Environment checks to ensure people were safe in their environment had not been consistently completed and this had placed people at risk of harm. We were concerned the systems and processes to ensure safeguarding referrals were made appropriately were not robust. This meant people were at risk of incidents not being reported to ensure external scrutiny of the service. Robust recruitment checks were not always followed to ensure staff were of good character. We found there were enough staff to meet the needs of people living on the residential floors however, people on the nursing floors had been placed at risk of harm as there were not always enough staff available to assist them when they required, and this had placed people at risk of harm such as skin deterioration. Staff knew how to recognise signs and symptoms of abuse and knew who to raise concerns to both inside the home and externally. Pathways to ensure safe admission into the home and between services were in place and were reviewed monthly. The home was clean and robust schedules ensured people were safe from the spread of infection.

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.

People and their relatives told us staff were approachable and they felt comfortable raising their concerns to them. One person said, “Yes, I feel comfortable to raise my concerns with the staff and tell them if something was wrong.” People and relatives told us staff did keep them informed when something went wrong however, we also received feedback that complaints were not always investigated and responded to. One relative said, “They keep in touch about any health updates, but I am not told about any changes to do with the home. I recently had to complain due to changes being made at the home, they said someone would ring me back, but they haven’t, and I have not received an outcome.” This meant the provider could not be assured lessons had been learned to improve the service and reduce the likelihood of the same incidents from occurring.

Staff told us the nursing and residential floors worked differently and did not always communicate well. One staff member said, “We did have a morning meeting, but the previous management worked different, 1 manager oversaw the nursing side, and 1 manager oversaw the residential side. I think there were issues, and they didn’t communicate so yeah, there was a divide.” This had led to a divide within the home meaning the sharing of information when something went wrong had not always been happened. This meant staff were unable to learn and reduce the likelihood of the incident happening again.

We reviewed accident and incident paperwork but were unable to find any documents to demonstrate lessons had been learned and we were unable to identify a lesson learned process. We discussed this with the interim manager and provider who agreed records were not in place to demonstrate lessons were learned when things went wrong. During our inspection we discussed with the provider they may wish to reflect and complete a lesson learned document to show learning from the current inspection, we did not receive this from the provider and were unable to assess the effectiveness and sustainability of any changes they intended to make.

People and their relatives told us staff completed a full assessment of their needs before they moved into the home. One relative told us, “We discussed a plan originally and then a couple of months ago we had a 1-1 review.”

Staff told us people’s needs were fully assessed before they moved into the home. When people moved between services staff provided a full care plan and medicine list to ensure a smooth transition.

We received feedback from healthcare professionals that staff did not always provide them with the information they needed to make clinical judgements. One healthcare professional told us, “I sometimes find that information is scant. Monitoring information is not always consistently undertaken.” This meant people did not always have their care needs identified and met which placed them at risk of harm.

We reviewed people’s care records and found detailed assessments had been undertaken before people moved into the home. This formed the basis of people’s care plans which were reviewed monthly as part of a ‘resident of the day’ process. This information was shared with new providers of care to ensure consistency. 10-minute morning meetings were in place for staff across all areas of the home to share updates. Including any new admissions into the home, people going out of the home and who was ‘resident of the day’ to ensure all heads of department spoke to the person to review their care, likes and dislikes and preferences.

Most people told us they felt safe living at Weymouth Manor. One person told us they did not always feel safe however, was unable to tell us why this was and said, “It doesn’t always feel safe, I can't explain it. There are some lovely staff here who look after me.” Another person told us, “I am very happy here and I feel safe.” Relatives told us their loved ones were safe. We received comments such as, “I really do feel [loved one] is safe and looked after”, “We feel [loved one] is very safe” and, “I do feel [loved one] is safe. It’s a lovely place with helpful staff.”

Staff told us they had received training and knew how to recognise and safeguard people from abuse. Staff knew who to raise any safeguarding concerns to. Comments included, “We would report to the manager and if not happy with the response, we would go higher to the regional [manager]. Outside of Weymouth Manor we would report to the local safeguarding team or to CQC.”

We observed staff speaking kindly and respectfully with people. People appeared to be comfortable living at the home, and in the company of staff supporting them. The atmosphere was calm, and people were relaxed. We observed staff supporting people to stay safe by giving their time to provide assurances when people needed them.

Processes were not always effective to ensure incidents had been appropriately reported to the local authority safeguarding team. This meant we could not assess and assure ourselves incidents were reported appropriately to ensure external scrutiny of the service. We discussed this with the provider who told us they would be implementing an audit schedule to make sure clinical governance was up to date. We were unable to assess the effectiveness and sustainability of this change at this inspection. We could not identify that a lessons learned system was in place to mitigate a further risk of harm to people living at Weymouth Manor when an incident had taken place, for example when there had been a medicine error. This had placed people at risk of harm. DoLs had been applied for appropriately however, staff were not always aware when people had conditions as part of their DoLs authorisation. Policies and procedures were available, and staff had attended safeguarding training updates to refresh their knowledge and understanding.

People and relatives provided mixed feedback as to whether they had been involved in creating assessments of people’s health, safety and welfare. We received comments such as, “I do not remember seeing a care plan, but we do have meetings we all go to where we have an opportunity to say what we would like to happen”, “A care plan was done at the start, I haven’t had anything since” and, “[relative], would have discussed the care plan, they’re very independent minded.” We received mixed feedback from relatives and whether they felt their loved one was protected from avoidable harm. One relative told us they often found their loved one in positions that could cause them to choke. This had been previous been reported to the management team however, continued to still be a concern. We fed this back to the interim manager who immediately implemented a managers daily check sheet and told us they were implementing ‘Home Champions’ to bring up the standards of care. The interim manager told us staff were in the process of completing their required refresher training. Other relatives told us staff followed instructions to keep people safe from harm. One relative said, “They safely hoist [relative] into their chair when required” and another said, “We like how they look after [relative], they remind them to use the walker as they will get up and forget to use it so could be at risk of falling.”

Staff told us they reviewed people’s care plans and risk assessments each month as part of the “resident of the day” scheme. Staff told us all the information they required was available in the person’s care plan and updates were communicated during handovers which took place at the start of each shift. One staff member said, “I think we do have enough information to manage risk. For example, we did have someone who had Warfarin and we had steps to follow if they fell.” Staff could describe what they would do if a person fell whilst taking any anticoagulant. When we asked staff how they involved people in decisions about their care and reducing risk of harm we received comments such as, “It depends on the persons capacity. Those with capacity, we go through everything together with them. Those with variable or no capacity, the families are involved. We had a person who liked to wear a hair piece and had fabric conditioner out on their side to clean it. We had a conversation with them about the risk to other people by leaving it out of the side and the person agreed to put it into a locked cupboard in their own room which they had access to.”

We observed staff did not always have the time to reposition people in line with what they had been assessed as requiring in their care plan. For example, on the day of our inspection we observed staff turning off a call bell and not returning to the person who required assistance until 20 minutes later as they had been assisting someone else. There were no other staff available to ensure people who required repositioning were repositioned in line with their care plan and the records we found supported our observations. We observed staff using moving and handling equipment safely.

Risk assessments had not always been effective at identifying and mitigating risks to people such as from risk of pressure sores and risk of constipation, this had placed people at risk of harm. We found a person not employed by the provider had slept in the home overnight however, no risk assessment had been completed and the person did not have a valid DBS. This had placed people at risk of harm.

On the first day of our inspection we found 1 person, who was a medium risk of falls, did not have a working call bell. This had been recorded in the maintenance book several days before however no actions had been taken. We fed our findings back to the provider who told us they would take immediate action to rectify this, however, the call bell was not working on the second day of our inspection. We brought this to the provider’s attention again and the call bell was replaced before we left the home. We have since received documentation to evidence the call bell is working and has been used following our inspection. Relatives told us they felt the home environment was safe. Comments included, “It’s a lovely environment, clean and fresh. Wide corridors with handrails, no obstructions everything put away where it should be”, “I used to do risk assessments in my job, so wherever I am, I'm looking and checking for risks. I see none at the home. It’s a safe environment. Wide corridors, clear of obstructions and clean” and, “It’s a lovely safe environment with caring staff.”

Staff told us the environment had not been checked since the maintenance person had left in April. One staff member said, “There is a book on the reception desk for us to report maintenance concerns, however, this does not get checked and we have to try fix things ourselves. Big things get put forward to the person who is head maintenance for all three homes, but I can’t remember when they were last here.”

We observed the environment was not always safe. The flooring in one of the lifts had ‘bubbled’ in the middle creating a raised trip hazard. Incidents of concern had been reported by staff in the maintenance books such as, “smell of burning” however, no actions had been taken since the maintenance person had left in April 2024.

Regular checks had not been completed to ensure the environment was safe and this had placed people at risk of harm. For example, the lift had not been maintained, the flooring had become a trip hazard, regular flushing to prevent Legionella had not been completed, and regular checks to ensure there were no problems with the fire and call bell systems had not been completed. Call bells were found to not always work. This had been reported by staff however, no action had been taken placing a person at risk. There was not a robust process in place so concerns relating to the health and safety of the environment could be reported and rectified. We discussed our findings with the provider who told a new person had been recruited to cover the maintenance position.

People and their relatives did not always feel there were enough staff to meet their care needs. We received comments from people such as, “I sometimes want more help, but they are always rushing around doing things, there is a shortage of staff” and, “There are some lovely staff here. They get very tired; you can see it in their faces, they are short staffed.” Other comments from people included, “I do use the call bell and someone comes and turns it off, they tell me they’re busy and will come back to me, but I end up waiting over half an hour” and, “After lunch, because I’m in a wheelchair I can be left in the dining room for some time before staff are free to come and take me somewhere I need to be. I find this distressing.” One relative told us, “Don't get me wrong the regular staff that are there are fantastic but when [relative] needs help, I struggle to find staff to help. They are very short staffed at the weekend.” Another relative said, “There is either not enough staff or new staff and agency staff are not given enough information or training. [Relative] gets dehydrated, the old staff would sit with and encourage them to drink, now the newer staff just look into [relative’s] room to see if [relative] has a drink next to them and think that’s ok but [relative] won’t drink it unless they are encouraged to do so” and another relative said, “I have noticed staff do not always get time to provide all the care my [relative] needs. I have noticed they are neglecting [relatives] teeth and I’ve had to remind them to do it.” Healthcare professionals told us they had concerns there were not always enough staff on the nursing floor. They had seen people impacted by this who had been left for long periods in wet bedding and clothing.

Staff told us there were not always enough staff, particularly on the nursing floor, to ensure people’s needs were met in a timely manner. One staff member told us, “The issues we have are with the staffing levels on the nursing floor. We are not able to get people washed and dressed when they want to. There are least 5 people who require support to eat and drink, and every person requires 2 staff to help them with their care.” Another staff member said, “The staffing is ok on the residential floors, but the call bells ring for long periods of time. We do answer them as quickly as we can, but often have to let them know we will have to return as [we are] busy with someone else” and another staff member said, “When I first started here, we were over staffed, this has changed recently and staffing can be a problem, particularly on the nursing floor if for example, someone calls in sick. We are now allowed to call the agency if we need to.” Staff told us whilst they had completed training, they did not always feel the training was of good quality. Comments from staff included, “the training is mostly e-learning, the quality is standard and I’m not confident it would be enough for new care staff” and, “My induction was fairly good, I was introduced to people and shadowed other staff, the training was mostly e-learning. Some of the training did prepare me for my role, but some not. I am still waiting for some training to be provided such as fire and first aid.” We fed back our findings and concerns that people were not always provided care in accordance with their care plans placing them at risk of harm. In response to this, the interim manager told us a system had been implemented by the management team which meant checks were completed daily to ensure people’s care needs were met. We were unable to assess the effectiveness and sustainability of this process at this inspection.

We observed a person who used the call bell to request assistance from staff following incontinence. The person had healthcare professionals waiting to assess them. Staff answered the call bell to let the person know they were busy with someone else but would be back with them soon. The person had to wait for a further 20 minutes before staff could assist them. This meant the person was at risk of their skin breaking down and the healthcare professionals were also delayed in carrying out their duties.

Safe recruitment practices had not always been followed. For example, we found 1 staff members full employment history was missing, and the reason for why 1 staff member had left their previous care support role had not been sought. This placed people at risk of being cared for by staff who were not of good character. We received the training matrix to review and identified some gaps in staff training. The provider told us they had plans to improve staff compliance with training.

People and their relatives told us the home was consistently clean. We received comments such as, “It’s a lovely environment. Clean and fresh” , “It’s a clean, well laid out modern building” and, “It’s a lovely place , clean fresh, spick and span.”

Staff told us they followed cleaning schedules to ensure the home was kept clean and free from the spread of infection. Staff had plentiful access to personal protective equipment (PPE).

We observed the home to be clean and tidy and had no concerns in relation to the spread of infection.

Cleaning schedules were in place to ensure the home was cleaned regularly including unseen areas such as the laundry room and kitchen.

Staff and relatives had no concerns about their medicines. We reviewed records which showed medicine errors with no people harmed had occurred, however learning had not always taken place to prevent the incident from reoccurring and this had placed people at risk of harm.

Staff told us they received training and a competency check before they were able to administer medicines. Staff told us their competencies were regularly reviewed. One staff member told us, “If there is a medication error there is a strict protocol that is to be followed.” However, a lack of robust processes meant the provider could not be assured lessons learned had been shared to prevent the incident from happening again. Rooms where medicines were stored were safe, clean and appropriately maintained by staff. Checks had been completed daily to ensure room temperatures and fridge temperatures remained within safe parameters. Staff administered medicines 1 by 1 from the medicine trolley, speaking to people to explain what their medicines were for. Staff signed to confirm medicines had been administered when they returned to their medicines trolley.

The home used an electronic system to ensure the safe administration of medicines. However, ‘as required medicines’ (PRN) had not always been administered in accordance with the prescribers instructions. People who were prescribed (PRN) medicines did not always have protocols in place instructing staff when, and how to administer medicines when they were needed. For example, we found a person had been prescribed medicines to prevent constipation. Staff had recorded daily throughout the month of May that the person had not used the toilet, however the medicine had not been administered since April. We asked a member of staff who told us, “The person is able to tell us if they need the medicine, but they do lack capacity. We do not ask them if they have been to the toilet and do not record this.” This meant the person was at risk of becoming unwell due to constipation. Further to this, we received feedback from healthcare professionals who told us, “Another issue is bowel management, often stool charts will indicate, or people will tell me there are issues with having their bowels open, but no bowel medication has been administered by staff and no monitoring or action has been taken when it is clear they need laxatives/additional medication requests.” There was a lack of robust systems and processes to ensure staff safely administered prescribed PRN psychotropic medicine, including sedatives to people. PRN protocols were not always in place to instruct staff when to administer the sedative medicines, and assessments had not effectively identified any risks to the person and to other people. This meant staff had not been provided with full instructions to keep people safe and to ensure the sedative was only administered as a last resort to prevent the overuse of sedative medicines.