41 West Hill

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 understood their duty to protect people from abuse and knew how and when to report any concerns they had to managers. When concerns had been raised, managers reported these promptly to the relevant agencies and worked proactively with them, to make sure timely action was taken to safeguard people from further risk. The provider had plans to involve relatives in the review process. There were enough staff to support people safely. Staff received relevant training to meet the range of people’s needs at the service. Staff received support through supervision and staff meetings to support their continuous learning and improve their working practice. Managers made sure recruitment checks were undertaken on all staff to ensure staff were recruited safely. Safety risks to people were not always managed well. Managers assessed safety risks to people and were in the process of reviewing care plan documents. The provider and staff working at the service did not always follow Mental Capacity Act 2005 principles.

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.

Relatives felt improvements had been made and a lot of learning had been completed by the provider since the last CQC visit. One relative said, “we’re listened to now and it’s acted on, it’s managed a lot better now.” However, people were experiencing restrictive practice without a clear care plan or assessment in place to demonstrate the reasons for needing the practice as stated within this report. Therefore, we were not assured that enough learning had taken place to understand and apply national guidance of ensuring the least restrictive options are applied when decisions are made to manage identified risks.

Staff were provided with an opportunity to learn when an incident or accident had occurred. One staff member told us “After an incident or if we have had to use restraint, we have a de-brief after to learn what we could have done differently and take any action.” Another staff member told us, “Accident and incidents records are read and reviewed daily now, and we complete a debrief to see what could be learnt. The registered manager completes a monthly analysis to look for patterns and trends.” The new registered manager told us the provider and staff team have learnt a lot since the last CQC inspection and took action to ensure people were safe and received good quality care. Staff and the management were able to explain the new processes to enable a leaning culture for incident management. However, we were not assured there was always an effective learning culture across the whole service. At our last inspection we found restrictive practices, and we continued to find restricted practice at this visit. For example, the snack cupboard had a lock on, staff and management could not explain the reason for this practice, and if everyone living at 41 West Hill required this level of restriction.

We found improvements had been made to some processes since our last visit. There was a significant improvement to the oversight and analysis of incidents and accident records. The provider implemented a more robust system to ensure better record keeping of incidents and accidents. Staff completed a form with detailed information including what had happened, who was involved, and the immediate actions taken by staff. The registered manager or another senior staff member reviewed each form to ensure they were detailed and included the identified actions. Staff were provided with the opportunity to reflect after incidents, to ensure learning and improvement could occur. Learning had been completed on the use of physical and chemical restraint. However, the provider did not have a holistic approach to ensure there was a learning culture throughout the service. For example, we continued to find restrictive practice. The provider had taken action after our visit. This meant the provider did not have an effective process and system to identify the risk and concern before our visit. There was a clear policy on the duty of candour. This policy guided staff to tell the person (or, where appropriate their advocate) when something has gone wrong.

Relatives told us staff were proactive at making contact with health professionals to obtain health support and advice when needed.

People’s health records were not always reflective of their attended health appointments. The new manager told us they had not audited people’s health action plans yet to identify the gaps but were aware they needed updating. A health action plan is a nationally recognised tool, to ensure people with a learning disability have clear records and support for their health needs. The deputy manager told us, “They [people living at the service] all attend their regular appointments such as opticians, dentist, and they have had their annual health checks. We work well with the pharmacy to ensure people are receiving their medicines on time.” Staff had worked with a range of health professionals to ensure they had the right guidance to support people with their health conditions. Staff had good knowledge of which health and social care professionals supported which people. The deputy manager and staff were able to explain when these professionals were to be contacted, and what type of support they offered. A staff member told us, “When we have taken a resident to an appointment we come back and log the appointment and any changes are shared during the handover to make sure everyone [staff] knows.”

Partners told us they felt assured people were supported to have their health care needs met, however records were not always reflective for example they had found gaps in people’s care plans.

Health records were not always kept up to date when a person had visited a health professional. For example, chiropodist visit record had showed people’s last visit was in 2023, however a chiropodist had visited a week before our visit. Where people required external health and social care support, documentation showed that suitable referrals had been made. For example, a person had an increase in epilepsy seizures, staff had made contact with the relevant health professionals.

People told us they felt safe. One person said, “I do feel safe because of the staff.” Relatives felt improvements had been made to protect their loved ones from abuse. Relatives told us if they had any concerns, they would report it to the new registered manager and if action was not taken, they would report their concerns to CQC. Where people were required to be supported in their best interests, we were not always assured the provider had applied the Mental Capacity Act to ensure restrictions were always necessary. The provider had not completed the necessary assessments or was able to explain why some restrictive practices were required. The use of restrictive practice impacted people’s freedom and human rights.

The staff team had a good understanding of safeguarding. Staff we spoke to were able to explain how to respond to allegations of abuse. Staff told us they had no concerns, but if they did, they were confident the management team would act appropriately. Staff were confident in using whistle-blowing processes if they felt concerns were not dealt with. One staff member told us, “If I see something I don’t agree with, or someone is being harmed, I will report it to the manager, I will report it to the police and CQC if needed and document everything.” The registered and deputy manager understood how to respond to allegations of abuse. They had a clear process of reporting safeguarding incidents and how to keep people safe. They told us, “I would report any safeguarding to the local authority, if it was a staff member we would suspend the staff member to ensure people are safe while ongoing investigations are happening, we would contact relatives if needed. If it was a police matter, I would report it to the police.” The management team told us they were further developing the staff team by empowering them to report safeguarding incidents to the local authorities if a manager is not in the service.”

We had observed a bruise to a person’s hand. Staff had failed to identify the bruise. Management did take immediate action to find the root cause and we were told it was from a recent hospital visit. Throughout, our onsite visit we observed staff working with people safely.

Staff had received refresher training in safeguarding since our last visit. In most cases, people were protected from restrictive practices, but we did find that people were not consulted when some activities had been restricted. The management team had reported safeguarding incidents to the appropriate authorities. The provider had made improvements to their safeguarding processes; this included detailed records from staff and a significant improved oversight by the management team. Where incidents had occurred, there were opportunities for staff and people to review what had happened to learn, prevent the re-occurrence of similar incidents, and monitor for trends and patterns. 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 MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to make particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. Staff had completed Mental Capacity training. However, we found The Mental Capacity Act and Deprivation of Liberty Safeguards (DoLs) was not always followed. These safeguards ensure people who cannot consent to their care arrangements in a care home are protected if those arrangements deprive them of their liberty. This meant people had unlawful restrictions imposed on them. For example, a person was deemed to lack capacity and additional monitoring equipment was put in place for them due to a change in their health condition. The provider had not completed an MCA assessment and no assessment was completed to demonstrate if the use of having two devices was the least restrictive option. Staff had also not applied for the suitable DoLS for the use of the additional equipment. The management team took action after our visit and updated the DoLs team.

Relatives had been given the opportunity to be involved in their loved one’s risk management plans. This meant people who knew people well could be involved to ensure their wishes and preferences could be considered. Relatives told us that staff understood their loved one’s needs well and offered support to keep them safe. One person said, “[person] not allowed to travel in the front of the car, [person] sits in the back, if [person] has a seizure, it could affect the driver, he’s been made aware of that, as he’d like to sit in the front but he’s happy with the reason.”

Staff and management told us they would try and involve people when managing risks but most of the people they support are supported in best interest, because they are deemed to lack capacity. Staff were able to explain the support they provided to ensure people were kept safe from identified risks . However, we were not assured staff always followed this due to our observations of blanket restriction applied during the onsite assessment.

We observed a snack cupboard to have a lock on and could only be accessed by staff. The provider could not demonstrate the reason for this, who had been involved in the decision making and if this high level of restrictive practice was needed to manage the identified risk. This meant all relevant people were not always involved in managing risks. Since our visit, the lock has been removed.

People’s communication needs were clearly recorded. This allowed staff to understand people’s needs/wishes and support them to stay safe. Staff had received Makaton training (form of sign language) to ensure they could communicate with people in their preferred method of communication. There were clear processes in place for how to respond to an emergency. Staff had clear evacuation processes to follow, and these processes considered the unique needs of people. Staff had received training on how to support people’s individual needs. Some people at the service could become distressed due to their health diagnosis. Staff had received training and had clear positive behaviour support plan in place on how to support people when they showed signs of distress. We found there was not always suitable risk management assessments completed involving relevant people and professionals when restrictions were in place such as locks placed on a kitchen cupboard.

Relatives felt the environment and health and safety was managed safely. Records showed people had been part of fire drills, so they knew how to evacuate the building in an event of an emergency.

Staff knew how to monitor the safety of the environment, and where to report any maintenance concerns to. Staff were confident that the building was well maintained to keep people safe. A staff member said, “We set the fire alarm to go off once a week to ensure the system is working, we check the fire doors are closing correctly. We also complete water temperature checks to ensure they are at the correct temperatures. If I find any concerns I report them to the senior, manager and have to record it in the maintenance file.” The management team described a clear process for monitoring the safety of the environment. For example, the provider documented their regular checks around the building and explained how they passed concerns to the maintenance team to resolve.

The home was safe if needed to evaluate in an emergency. Corridors were clear of any blockages, allowing people to follow easy to read escape routes. Staff had access to fire-fighting equipment. We observed a person living at 41 West Hill supporting staff to complete fire checks of the home. This meant people were given an opportunity to be involved in the safety of their home. Windows were unable to be opened wide. This safety feature prevents people from falling or climbing out and is in line with guidance from the health and social care executive. The home was safe in the event of a fire. Corridors were clear of any blockages, allowing people to follow easily to read escape routes. Staff had access to firefighting equipment throughout the home and fire alarms were throughout the building.

The environment was kept safe, by regular checks and maintenance. We saw there had been regular checks to ensure the home was safe in the event of a fire for example, staff completed weekly fire alarm and building checks. The gas heating system was regularly serviced to prevent harm to people. Systems were not always in place to ensure the water quality was maintained to reduce the risk of water-bourne bacteria like legionella. Annual water sampling for legionella had been completed. However, the provider had an internally completed legionella risk assessment in place but could not demonstrate staff completing the risk assessment had the relevant training, in line with the guidance from the health and safety executive. The provider took immediate action and told us they had booked an external company to complete a legionella risk assessment.

Relatives told us there were enough staff and that they were well trained. Relatives felt improvements had been made as staff have had additional training and a new manager has been recruited. One relative told us, “[person] has PDA (Pathological Avoidance), all staff who are working with him are now aware of PDA, they need to be trained in it, [person] presents as an able person, if people are not trained, he can get behaviours quickly, so long as staff are trained and know [person], they can manage it in the time. Only one occasion since the new manager, things may not have been put correctly to [person]. Previously there was lots and self-harm. Since the new manager, has been there, very few incidents of self-harm, some could not be avoided, he's there for a reason.” From our observation and review of the providers processes of people’s commissioned hours we were not assured people were always receiving the experience and hours of care and support that was commissioned.

Staff had received appropriate training to ensure they could do their role effectively. Staff felt the additional training that had been provided helped them to support people safely. A staff member said “We have enough training. There are 31 trainings to complete online, and we have also completed face to face training, Makaton, Non-Abusive Psychological and Physical Intervention (NAPPI), restore 2 and safeguarding. It was good refresher training and we have implemented a lot of the training; it’s been very helpful. This is why people are getting more safe care now.” Staff told us they had regular opportunities to meet their manager on a 1-to-1 basis for supervision. These meetings gave them the opportunity to feedback about their experiences and request further guidance/training if needed. A staff member told us, “We have a staff meeting every month, we also have a communication book that we have to read before our shift to ensure we are aware of any changes since our last shift and we have one to ones, my last one was 3 weeks ago.” Management told us improvements had been made to the rota. A manager told us, “We have made improvements to ensure people can leave and access the community when they want, we have one staff member who floats and me or the registered manager step in if people want their 1:1 or 2:1. For example one weekend I come in to ensure people can go out when they want.”

We saw there were enough staff to provide support to people safely. However, we were not assured that people had always received their commissioned support. For example, one person was commissioned to have 2 staff members for 4 hours a day to access the community. We observed a person had not received this support. We asked the staff member in charge, and they told us because it's raining the person would not be going for their walk. We did not observe other alternative options to ensure people receive their commission support.

Since our last visit staff had received suitable training to do their role. The management team ensured there was always suitably skilled staff working. Staff had received training on how to support people’s individual needs. For example, staff had received further training in Pathological Avoidance (PDA). Once staff were trained, there were clear ongoing processes to check their competency. Safe recruitment processes were followed. For example, previous employers were contacted to give references on the staff member. Staff had regular Disclosure and Barring Service (DBS) checks. These check the police database for convictions or warnings that may impact the staff members safety to work with people. We were not assured people always received their commissioned hours of support. Where people had been assessed to have 2 staff for a certain number of hours a day care plans did not provide clear information and guidance to staff on how these hours were to be used. For example, there was no guidance on what to do if things such the weather was not suitable for an outside activity what should be offered to people. The management team told us, they do bank people’s hours and use them for when they go on day trips. However, we could not see a robust system and process in place to demonstrate this.

People and relatives told us that the home was always kept clean.

Staff had received food hygiene training, they recorded open and discard dates on foods stored in the fridge to reduce the risk of food bourne infections. One staff member told us, “I have completed online food hygiene training. We have to take fridge and freezer temperatures daily; we ensure we rotate stock and have to label open dates for the foods that stored in the fridge.”

We saw that staff had access to personal protective equipment (like gloves). This allowed them to support people in a hygienic way. We observed bathrooms had fabric pull cords which were visibly unclean. The fabric nature of these cords meant the dirt was engrained. The dirt on these pull cords could result in infection control issues when people pulled the light switch. The provider told us they would obtain advice from infection prevention and control team. We saw the kitchen was managed in a hygienic way to ensure people did not get food-bourne infections.

There were clear processes and policies, to ensure the environment was kept clean and hygienic. This protected people from the spread of infection. Staff had received training in infection prevention and control, how to put on protective equipment and how to keep people safe in the event of an infection outbreak.

Relatives told us that they were involved with reviews of their loved one’s medicines. One relative told us, “Since the new manager started, I have been involved.”

Staff had completed medicines training and had a competency assessment. Staff and management were able to explain how they supported people to take their medicines safely. Staff knew who to report medicine concerns to. For example, if they felt a person’s medicine was no longer effective, they understood which health professionals to contact. The deputy manager told us, “We do online training to ensure its up to date if errors had been made, we have created a staff knowledge booklet to check their competency’s and we have signed staff to further develop and enrolled onto NVQ level 2.”

Medicines were managed safely. Medicines were stored in a locked area, to prevent people accessing them unsafely. We found a significant reduction in the use of ‘as needed’ medicine for the use of chemical restraint since our last visit. Staff kept clear records of when they had given prescribed medicines. We saw medicines were given as prescribed. Staff did regular checks of the amount of medicine in stock. This ensured that suitable stock levels were always in place, and more medicine could be ordered from the pharmacist as needed. Staff had received training on how to administer medicines safely. The management team had regularly assessed the staff’s competency, to ensure they were following best practice.