Westmead

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 6 quality statements. People were not cared for sufficient numbers of suitably deployed staff in safe living environments. Medicines were not safely managed. The provider did not have an effective safeguarding process in place. Risks to people had not been adequately assessed, monitored and reviewed. We identified 4 breaches of regulation in relation to safe care and treatment, safeguarding people from abuse, premises and equipment, and staffing.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were not safeguarded against the risk of financial abuse. For example, there were no mechanisms in place to ensure purchases made with or on behalf of people were legitimate. Some people were provided with meals out and drinks without cost, whilst others were paying for these items. There was no reasonable explanation for the difference in practice.

Some staff were unclear about reporting concerns outside Westmead. This was particularly concerning as staff told us they did not feel confident about raising safeguarding concerns with the management team.

Not all safeguarding incidents were reported to ourselves and partners by the management team. When looking at complaints and safeguarding concerns, we identified 3 allegations of abuse raised by relatives which had not been formally reported by the provider. Financial audits for people's monies were not completed in December 2023 and January 2024. The provider's finance team identified 62 instances where receipts for purchases were not in place between October 2023 and March 2024. The missing receipts were across a range of purchases, not only people’s personal finances.

There was a lack of management oversight of people’s experience of their care and support when in their own homes. This meant the provider could not demonstrate safeguarding processes were in place to keep people safe. Scrutiny and debriefs of incidents where people were restrained were not swiftly carried out. This meant safeguarding concerns could not be quickly identified and acted upon, which left people at risk of abuse.

People were not always involved in managing risks connected with their behaviour. Staff did not all know the strategies to use to de-escalate situations and help prevent injuries occurring. Some staff lacked understanding of how people were involved in managing risks, because they had not read their support plans. We found an incident with one person had been inappropriately responded to, by staff removing the person’s clothing due to a perceived risk of the person choking. This was not an approved response within the person’s support plan and there was no evidence they had been supported adequately. We identified 2 incidents in May 2024 when another person was exposed to a serious risk of harm. Opportunities to reduce risks after the first incident had not been followed up.

Some staff did not always understand individual risks to people as they said they did not have enough time to read care plans and risk assessments. Staff did not always feel sufficiently confident in responding to incidents of behaviours which may challenge others. This meant people were at an increased risk of harm.

We observed there were no fire drills taking place for 2 of the bungalows. At the end of May 2024, a fire safety panel within the laundry room had a light showing ‘system fault’ and ‘general fault’. It had been identified by the provider’s external contractor that the fire system was not fit for purpose during their checks. We made a referral to West Yorkshire Fire and Rescue to request they visit Westmead as the recommended date for the next inspection was showing as 2 March 2022. One person only had limited access to the local community. Despite having access to a personal vehicle, this was not used due to risks perceived by the provider and their activities were limited to those that took place in the home, or within a short walk of their home’. There was no evidence to show this person or their relative had been sufficiently involved in managing these risks.

Scrutiny and debriefs of incidents where people were restrained were not swiftly carried out. People affected by these risks and their representatives had not been involved in these processes. This lack of management oversight placed people at an increased risk of harm as action had not been taken to reduce risks to people.

One person's accommodation smelled of damp and there was a lack of ventilation. There was a missing toilet seat, black areas in the bathroom and around their window. We observed damage to the flooring and staff told us there had been a maggot infestation between the floorboards. Sealant was missing around skirting boards. In another person's accommodation, we saw a badly stained carpet which was replaced by the 3rd day of our assessment. However, the carpet had been glued to the floor without any underlay, resulting in a very hard surface. This posed a serious safety issue to the person who lived there due to their behaviour. We found holes in walls. There were loose electrical sockets and some windows without blinds or curtains, including in staff accommodation. Despite being aware of some of these issues, the management team had not taken timely action. One relative had been seeking repairs in the accommodation of their loved one for several months. At the time of our assessment starting, this work had commenced.

People did not receive all their funded hours as shown on the staff rota. There was a shortfall in the support hours provided for 3 people each day, as this was was not allocated to them. We also found 1 person received extra hours of support each day that was not funded. Staff breaks were not always covered and people who were allocated 2 staff members were left with 1 staff member during some periods. We found evidence of this during a walk around on 28 May 2024 when we saw reduced staffing for 3 people. There was a high turnover of staff. Some less experienced staff did not know people's needs well enough and were not confident in responding to periods of crisis. Feedback from some family members and staff said this had a direct impact upon the management of incidents with people and this had been the case for a significant period of time.

We found staffing was not always adequate to provide safe care to people. We looked at 4 weeks rotas from April to May 2024 and 5 weeks rotas in November to December 2023 and found shortfalls in staffing levels for both days and night shifts. There were several occasions when nights had no senior staff working and some instances when day shifts fell below the number of senior care workers needed.

Staff deployment was not effective to support people’s individual needs. Staff who did not know people well were deployed to work with them, which resulted in situations escalating and increases in incidents. Some staff described incidents whch could have been prevented if the staff team were more skilled, knowledgeable and confident about people’s needs. Staff did not always take their breaks and worked excessively long hours at times. Some staff worked a 14 hour day shift, followed by a sleep shift and then another long day shift. Staff told us their sleep shifts were often disturbed because of the need to support people in the night. We spoke with the management team, who told us the rotas were done off site and staff usually had rest periods. There was a lack of effective oversight to ensure staff worked safe hours. Management told us little or no supervisions were completed in 2023. Staff appraisals had not been taking place.

We found people’s accommodation was not cleaned thoroughly; some people’s living areas were visibly dirty. Hazardous cleaning materials were not stored safely; cupboards containing cleaning chemicals were accessible and unlocked. A yellow clinical waste bin outside a person’s apartment had a broken lid and visible waste bags exposed. The manager’s walk round on 13 and 27 February stated ‘yellow bin to be ordered as current is worn/dirty’ yet this had not been actioned at the time of our inspection.

Records relating to the use of anti-psychotic medicines did not show the reason why these medicines were being administered. On one occasion in June 2024, staff had exceeded the prescribed number of administrations of one person’s medicines in a 24-hour period. This had been identified by relatives, rather than the provider. Other aspects of medicines management were found to be satisfactory.