Westhope Place

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

Staff did not consistently protect people from abuse and improper treatment. They did not always identify allegations of abuse or make referrals to the local authority under their safeguarding policy. Staff did not always assess risks to people's health and safety or mitigate them where identified. Risk assessments were incomplete and did not include risk that were identified during our assessment. People did not always have care plans to guide safe practice. Medicines were not always managed safely. Environmental checks had not always considered potential risks identified by the providers internal governance processes for example Fire Risk Assessment actions had not been monitored or implemented fully.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were not always kept safe. Staff and leaders had not promoted an open proactive culture to safety events. Incidents were not always reported or investigated this resulted in failures to learn lessons and continually embed good practice. We observed people carrying out self-injurious behaviours. Staff confirmed this was a known behaviour which for one person had increased recently. Incidents had not been reported or investigated and as a result the provider could not be assured people lived safely as risks had not been assessed, mitigated or monitored. This meant opportunities to improve practice to reduce harm had not been investigated or considered.

The manager and staff did not operate a proactive, open approach to safety events and failed to provide assurance they monitored safety events effectively. One staff member speaking of incident reporting told us, “There is no system”. Another told us, “I asked last week when person scratched themselves, there are no ABC or incident charts.” We checked for records of how safety events had been reported and lessons learnt and the director told us, “They were unable to locate records.” This failed to demonstrate effective incident reporting systems and monitoring shortfalls in reporting concerns or provide assurance lessons were learnt.

Providers processes had failed to identify shortfalls in staff practice and as a result self-injury to people had not been fully investigated. The provider could not provide assurance incident reporting processes were robust or effective and as a result some people experienced avoidable harm. Following our assessment visit we sought urgent assurances from the provider of the actions they were taking to ensure people’s immediate safety and well-being. The provider told us they carried out a full review of peoples needs, reviewed risks to people and ensured concerns with staff practice were addressed.

People did not always receive continuity of care when admitted from another service to Westhope Place. We reviewed experiences relating to one person who had moved into the service recently. Managers and staff had failed to establish and monitor safe systems of care including significant risks associated with epilepsy and behaviours of concern.

Staff had not received consistent information or guidance to ensure safe systems were established for people. A staff member spoke of “Inconsistent and contradictory information”, relating to a person’s support needs. Managers had failed to ensure continuity of care. For example, records related to a person’s needs included information about the gender of staff who they responded to well. This information had not been considered ahead of their move and resulted in the provider needing to provide additional male staff in order to mitigate risk. Following our assessment visit the director informed us they were not able to meet this person needs at Westhope Place.

Partners shared information evidencing significant concerns with safe systems of care following a person’s admission to Westhope Place which had resulted in the person being admitted to hospital. Safeguarding enquires had identified significant shortfalls with staff understanding of epilepsy and medicine practices. Whilst enquires were ongoing it was apparent managers and staff lacked skills and competence which resulted in this person not always receiving safe care, exposing them to potential avoidable harm. Partners and the provider were working together to ensure safe systems of care were implemented to mitigate potential risks to people.

Safe effective systems were not in operation to ensure people received continuity of care which met their needs. We checked and the director was unable to provide evidence of a pre assessment which managers should have completed prior to a person moving to the service. The director told us of actions they were taking as a result of concerns about this persons epilepsy support which included gathering a full medical history, a review of medicines and ensuring staff could access tools and support to monitor epilepsy risks.

People were not kept safe from avoidable harm because staff failed to understand how to protect them from abuse. Managers and staff had failed to consider self-injurious behaviours within safeguarding processes. The Social Care institute for Excellence (SCIE) defines the “Inability to avoid self-harm” as a type of self -neglect and as such managers and staff have a responsibility to report within safeguarding processes to ensure people receive appropriate support to mitigate and minimise the risk of harm. Furthermore, people were not always protected from the potential risk of inappropriate restraint. A number of people were subject to Deprivation of Liberty Safeguards (DoLs). The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty had the appropriate legal authority and were being met. Managers did not have effective systems to ensure DoLs and any conditions were managed safely. One persons Dols conditions included them being referred to Speech and Language for assessment (SaLT). This was issued July 2023 and had not been followed up by the provider as a result increased potential risk of harm. Following our assessment visits the director told us they had now completed the referral.

Managers and staff were not clear on their safeguarding responsibilities. The provider had instigated a review of available information, and the director told us, “Limited information is available in relation to previous compliance with the DoLs conditions”. The provider could not be assured managers had acted in accordance with their regulatory responsibilities. The director was reviewing incidents to check statutory notifications had been submitted to CQC and the local authority alerted to potential safeguarding incidents. Staff demonstrated a lack of knowledge about safeguarding processes or when to escalate incidents. Staff members were asked their understanding of Mental Capacity Assessments, restrictive practice assessments and consent and several staff told us they did not know what this was and didn’t know where to find them. Following our assessment visit we sought assurances of the actions the provider was taking to ensure people were safeguarded from harm. The provider took immediate action to investigate failures in managers and staff safeguarding awareness and responses.

We observed staff not always keeping people safe from avoidable harm. We saw people carrying out self-injurious behaviours and asked staff what processes they followed in theses circumstances. Staff were unable to provided details of how this was recorded or investigated and when prompted one staff member told us, “This had not been recorded [previously] but will be done today”.

Effective systems were not in operation to manage safeguarding risks. The provider could not be assured safeguarding training was effective. Records showed that staff compliance in safeguarding training was at 76% however, there was significant evidence managers and staff had not considered self-injury as abuse which had resulted in people experiencing potentially avoidable harm. Dols processes had not been effectively monitored which meant restrictions had not been reviewed a number of peoples Dols had expired and were several years out of date. This meant the provider could not be assured restrictions remained the least restrictive option for people.

People did not always live safely and free from unwarranted restrictions. The service had not always assessed, monitored or managed safety well. Choking risks had not always been managed safely. CQC were notified of a persons unexpected death following an episode of choking. The circumstance around their death is currently subject to coroners and police investigation. The provider was working with the local authority and other agencies to ensure other people’s risks were assessed and managed. At the time of our assessment, multiple agencies were completing a review of peoples choking risks to ensure people were supported safely.

Staff did not always possess the information and knowledge to work with people’s individual needs or keep them safe. One staff member spoke of their concerns with accessing important eating and drinking information and told us, “I have never seen a SaLT plan for [person], … we complained to management for better information.” Staff spoke of confusing and sometimes contradictory information in peoples care plans which impacted on staff ability to access accurate information. The provider could not be assured they could access accurate information regarding people’s risks. The director spoke of challenges they had accessing accurate information due to being unable to contact service managers and told us, “We have been unable to consult with them in the way we would usually do, to gather information in relation to historic documents and activities at the service.” Following our assessment visit, the provider took action in consultation with commissioners to review and reassess whether Westhope Place was the appropriate service to meet people’s needs safely. They made arrangements for additional support and told us, “Senior managers are present in Westhope Place on a daily basis providing oversight, direction, coordination and support to the staff team”.

Staff were observed supporting people in communal parts of the service. People were observed being supported with meals and drinks in accordance with recently reviewed dietary guidance. Staff spoke about peoples eating and drinking risks and their increased understanding of modified diets. We observed staff supporting one person to transfer into their wheelchair and raised concerns with the director who took action to address this and ensure staff supported people in line with their moving and handling assessments.

Risks to people were not always identified or managed appropriately. For example, a communication risk assessment included information about how the person may display distress if they were upset which included the potential of them “hitting staff”. There was no information to guide staff on actions to take or monitoring for specific triggers. There was a failure to ensure staff were provided with appropriate training and guidance. Staff told us this person had been increasingly upset recently. The failure to ensure risk assessments were monitored increased the risks of people not receiving appropriate support in a consistent and safe way.

People were not always kept safe from potential risks in the environment. The provider had not always effectively managed risks associated with fire safely. The provider failed to adequately assess people’s individual risks associated with evacuating the service in the event of an emergency. Personal Emergency Evacuation Plans (PEEPs) were generic and lacked guidance for staff as to how to support individuals to evacuate in the event of an emergency. This meant peoples mobility needs had not always been fully considered as part of their plan. We raised this concern with the director of quality who provided assurance actions would be taken as a matter of urgency.

Some staff told us they did not know where to find information relating to emergency fire actions and that this had not been covered in their induction. One said, “I don't know I haven't been told”. Another experienced staff member was unable to locate the fire folder expected to contain the information staff needed to support people in the event of an emergency. We sought urgent assurances from the Director of Quality as to actions they planned to take to mitigate risks to people. They confirmed staff on duty would receive additional training and support and this to be covered by all staff, PEEPs were being reviewed, additional evacuation equipment was being arranged and outstanding actions from the Fire Risk Assessment (FRA) were being prioritised.

Observations of staff practice did not always provide assurance potential risks in the environment were safely mitigated. For example, we saw multiple folders in both managers office and communal areas and staff were unable to locate guidance they might need in the event of an emergency. Observations of the environment confirmed some safety checks were being completed for example, moving and handling equipment had been serviced in line with regulation.

Effective systems were not operating effectively to detect and control potential risks in the environment. The providers FRA had identified improvement actions including for the service to carry out fire evacuation drills at night. This would provide an opportunity for the service to check their arrangements were sufficient to keep people safe in an emergency. This had not been completed and as a result the provider had not reviewed or controlled potential risks. Health and Safety Audits had identified the need for the fire evacuation strategy to be shared with staff. This action was recorded as complete two weeks ahead of our assessment visits. We have reported a number of staff were unable to demonstrate their knowledge of the fire evacuation strategy. The Quality Director provided assurance of actions they planned to take in response to identified shortfalls in health and safety processes in operation at Westhope Place.

People were not always supported by staff who had effective training to meet their needs and keep them safe. Staff were observed supporting a person in a communal area with moving and handling techniques which had not been assessed as safe. We raised concerns with the director and they provided assurance of actions they would take to ensure staff were provided with appropriate support and training to support people safely.

The provider did not always have clear oversight of staff skills and development. Moving and handling training and competency assessments had not been completed in line with the providers policy. The director told us, “Our organisational requirement is that Moving and Handling training is renewed annually by way of the trainer assessing the competency of staff as part of their practical element of training and managers are then expected to oversee this in their role/as part of supervision. Unfortunately, as [the manager] remains absent we have been unable to confirm the local arrangements for undertaking and recording this supervision.” Records of training showed a high percentage of staff completion however, feedback from staff and records within care plans evidenced their lack of competency and skills. One staff member told us of their induction process,” Only had training online on day 2 …This is a place forgotten about, no manager, whoever was before messed up, I was horrified.” Generally, staff spoke of how they felt they had not been listened to or received effective support from managers prior to a person passing away.

We observed staff not always engaging with people in a safe manner. We sought assurances from the director regarding staff moving and handling practices and medicine administration during our assessment visits.

The provider has not ensured managers were monitoring staff practice and as a result some people did not receive safe support. Staff training and competency processes were not always completed or effective. For example, Moving and Handling training and competency assessments were not completed in line with providers policy and as a result there was a failure to identify poor staff practice which potentially increased risk of harm to people. Whilst there were enough staff deployed they did not always receive the support and training to ensure they met people's needs safely and effectively. Staff were consistently recruited through an effective recruitment process that ensured they were safe to work with people. New staff were expected to complete the care certificate. The care certificate is a set of standards for health and social care professionals, which gives everyone the confidence that workers have the same introductory skills, knowledge and behaviours to provide compassionate, safe and high-quality care and support.

People were not always supported to manage potential risks of infection. Staff did not always follow good practice food hygiene guidance. Meals were prepared by staff and given to people with out due attention to temperature checks. Whilst the service needed some refurbishment generally the service was clean.

During our assessment visit one staff member demonstrated a lack of awareness of the importance of cleaning up medicine spills. We prompted them to ensure this was dealt with to manage the risk of cross contamination and infection.

We observed staff supporting people with meals which had not been checked in line with food hygiene processes. Staff were not always following food safety processes. There were no available records of completed checks.

Risks associated with food preparation had not been effectively mitigated. The providers processes, Health and Safety Audit and Infection Control Audit failed to identify this as an area of risk. The service had not been able to demonstrate they followed the principles of good practice guidance such as Safer Food Better Business (Food Standards Agency) and as a result could not be assured, they were effectively mitigating potential risk.

People were not always supported to access pain relief. One person was observed holding their hand to their head, we asked staff what their processes would be to check whether they were experiencing pain. The staff member was unclear. We checked with a senior manager who confirmed this person was not prescribed pain relief and they would address this to ensure they had access to pain relief. People did not always receive medicines safely or in line with good practice guidance. A staff member was observed taking the medicine from a person’s storage cupboard, dispensing the medicine and administering it to the person in advance of checking the Medicine Administration Record (MAR) to confirm they had given the right person the correct medicine at the correct time and dose. This was not in accordance with National Institute for Clinical Excellence, (NICE) good practice guidance. Shortfalls in medicine administration processes potentially increased risks to people.

Staff we spoke with were unable to access detailed information or explain their understanding of the importance of medicines for specific health conditions such as epilepsy. We reviewed the MAR record for one person which had two missing signatures relating to the administration of epilepsy medicines. Staff had not reported this concern and as a result they could not be assured this person had received medicines in line with their prescription. We raised a number of medicine concerns with the director, and they took immediate action to investigate shortfalls and address staff practice.

There were significant shortfalls in staff medicine practices. There was a lack of suitable arrangements in place for obtaining, administering, recording and auditing of medicines systems. For example, we found staff were not always administering medicines in line with Accomplish policy or (NICE) good practice guidance. Staff competency checks had not always been completed and as a result the provider could not be assured people always received medicines safely. Managers and staff did not carry out regular stock checks for medicines and records of audits did not identify the significant shortfalls identified at assessment. We were not assured the processes in place to manage medicines were robust.