Archived: Welham House

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 several breaches of regulation in relation to people's safe care and treatment and how people are protected from abuse and improper treatment. We assessed all quality statements in the safe key question and found areas of concern. There were signs of a closed culture at the service. Staff did not consistently protect people from abuse and improper treatment. People were not always believed when they raised allegations of abuse. Not all safeguarding’s were reported to the Local authority this was not in line with the providers policies. People received care from staff that had not received the required training to support them with administration of specific medicines. Staff did not plan care appropriately or support people to manage triggers known to cause agitation. Risk assessments were not used effectively when people were supported to access the community. This placed people and the public at risk. Incidents were not recorded in accordance with the providers policy. The service was not secure, with a risk that the service could be accessed by unauthorised persons as well as risks that people with restrictions in place would be able to leave without staff being alerted. The environment was not well maintained with several hazardous broken items accessible to people.

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.

There was not an open or positive culture at the service. People were not always believed when they made allegations of abuse. One of the people living at the service would become agitated when other people or staff went out in the service vehicle. The staff had not planned for this known trigger and had not been able to manage the situation, resulting in damage to the vehicle and causing distress to other people. We spoke with a family member who said that they had notice changes, with an increase in their loved one becoming distressed and damaging property. However, they had not been part of a review.

Concerns of safety were not always listened to by staff and senior leaders. We spoke with staff who had been involved in incidents they told us that they had not received debriefs and were not aware of any learning from incidents that they had been involved in. We found some incidents had been recorded in the diary with no incident forms available when we visited the service. Following the inspection the provider completed an action plan which stated incident forms had been completed, however, these did not state when they had been completed. Despite a person at the service having known triggers around vehicles we witnessed a delivery that staff had not prepared for or assessed the risk of them coming on to the drive. There were continuing themes of poor practice taking place. Staff, managers and senior leaders had not learned from breaches in regulations highlighted in the last CQC inspection in September 2023.

The provider had not ensured processes to ensure people’s safety were effective. They did not have effective oversight of the service and had not made effective changes following the last CQC inspection in September 2023. We reviewed incidents at the service and found that they were not recorded in a timely manner. We found evidence of at least 4 incidents in June 2024 had not been recorded. The manager did not know all the details of these incidents or if they had been reported to the local authority. Additionally, a senior manager sent messages through the electronic care records system prompting staff to complete records. We reviewed an incident form from October 2023 where staff had stated physical restraint had been used. However, the record lacked detail to evidence the reason for the restraint. The failure to accurately record behaviours at the service, impacted on the ability to review incidents, improve staff practise and ensure peoples care plan are followed. We saw emails stating that debriefs did happen. However, staff told us this did not happen for all significant incidents. Learning did not take place and the risk of harm to people was not reduced. This placed people at risk of avoidable harm as there was a lack of oversight of incidents from the provider.

We were not able to obtain enough information to comment on this quality statement

We were not able to obtain enough information to comment on this quality statement

We were not able to obtain enough information to comment on this quality statement

We were not able to obtain enough information to comment on this quality statement

People living at the service were not always kept safe from abuse and improper treatment. People were not always believed when they raised allegations of abuse. Some people living at the service were displaying agitated behaviour which was poorly managed and placed other people living at the service at risk of physical and emotional abuse. One person had raised allegations of abuse from a staff member. This was not dealt with in a timely manner. As the provider believed the allegation to be untrue there was a delay in reporting this to the local authority safeguarding team. We spoke with family members who were not satisfied with outcomes of staff investigation. They told us that there loved one had been shouted at and sworn at by staff. Family told us that they had spoken to the provider who had assured them that the staff member would no longer be working with their loved one.

We spoke with a senior carer who told us they had not felt supported by the provider when raising safeguarding concerns and had received conflicting advice from senior leaders and the provider when it came to reporting incidents to the local authority safeguarding team. We spoke with the manager of the service who had been in post for 2 weeks, around safeguarding issues that we had been identified during our visit to the service. Neither had recognised the risk to a person who was having contact a staff member who was no longer allowed to work with vulnerable people. Following the inspection the provider told us that they would implement safeguarding refresher courses for staff and that the manager was to attend a safeguarding ambassador course. During our assessment the service were being supported by a care consultancy agency funded by the Local Authority. They had expressed that the former manager had not been supported to by the provider to raise safeguarding incidents.

We observed people experiencing distress and being agitated. One person experienced several episodes of distress throughout our visit. Staff did not act quickly or support the individual this led to incidents where other people at the service were harmed, and property was damaged. There were several incidents during the day where had staff been more aware or acted sooner could have been resolved before becoming an incident. De -escalating strategies were not effectively used during these incidents. This placed people at potential continued abuse. We observed staff failing to record these incidents accurately or in a timely manner. We observed there to be no information in the service to support people to understand how to keep themselves safe. We observed that despite there being a sign on the front door stating that it should always remain closed that staff and people at the service left the door open. Due to the door being open and in frequent use the doorbell was constantly going off, staff did not always respond or react to the doorbell sounding. Putting people at risk of unauthorised entry. However, when we arrived there was a trades person who had been refused entry as they did not have any identification. During our visit staff had supported 5 people to go on a trip to the beach. Staff failed to take adequate measures to protect people from the effects of sunburn. At least 2 people returned to the home with visibly red skin from exposure to the sun. Staff were not working in line with the providers safe, weather policy.

Safeguarding processes were not effective. Although staff had received training in safeguarding, staff and managers were not following the providers safeguarding policy. This led to serious safeguarding concerns going unreported and not investigated. We found physical and chemical restraint had occurred to people with no records in place to demonstrate the reasons and why. We found little evidence of staff referring and using Positive Behaviour Support and consideration of de-escalating strategies. These are indicators of a continued poor management of safeguarding, positive behaviour and a continued closed culture. We found that staff who had been accused of being involved in abusive situations towards people at the service had not had their employment restricted pending investigation of allegations. Processes to safeguard people from financial abuse were not always followed. We saw receipts for when people at the service had gone out for a meal. One person’s bank card had been used by staff to pay for the persons and their peer’s meals. There were also unaccounted items on the receipt that when asked the person they said that the items were meals for the staff. This meant people were not protected from a significant risk of abuse.

People living at the service were not supported to manage their known risks safely. One person living at the service restrictions in place. These restrictions had been implemented to keep the person and the public safe. Staff did not always follow the restrictions putting the person and the public at risk. Another person was known to vandalise property. However, the environment was not kept free from items they could use to as weapons or as a means of vandalising property. The service had an open door policy. Which meant the front door to the service was unlocked between the hours of 8am till 10 pm. People living at the service greeted visitors at the door, they were very pleased to see visitors but did not understand the risk to themselves by their home being accessed by unauthorised persons. During our visit to the service, the staff organised a trip to the beach. Five people and 2 staff members went on the trip. Staff had not supported the people to recognise that it was a very hot day and that they would need sun cream so some came back with sunburn.

We spoke with staff and leaders they were aware that 1 person had Home Office restrictions in place but did not understand what those restrictions meant or the impact on the person if they did not follow the restrictions. A staff member we spoke with had not felt able to inform the new manager that they did not feel safe supporting 3 people to access the local community on their own. Managers and leaders that we communicate with did not understand vulnerable people may need support to make informed decisions and that they should protect them.

We observed people not being supported effectively to manage risk. There was a person who was known to become distressed and agitated when people were using the services vehicle. However, we observed the vehicle to be parked outside the persons bedroom window when people were accessing the vehicle.

The provider had failed to have oversight and recognise that staff did not follow processes that were in place to manage risk. The manager was new to the service, but not new to the role of registered manager. They were not aware of all risks, staff abilities or conditions in the service as they had not received a handover from the provider. One person had some restrictions and putting them at risk of breaching their restrictions as well as risking public safety. A person who lived at another service run by the provider had a risk assessment in place to support them when carrying out gardening duties. However, whilst at Welham House this risk assessment was not followed as the person was not supported to ensure all gardening equipment was put away securely. This led to the gardening equipment being used by a person who lives at the service to vandalise a car.

People living at the service had not been supported to recognise risks within the environment of their home. All internal fire doors on the ground floor of the service had been propped open with door stops. We requested that these were removed. As the people living at the service were used to the doors being open, they were looking for and returning the door stops. People at the service had used gardening equipment that had been left unsupervised to vandalise a car. People had not been supported to keep their bedrooms clean, tidy or safe. One person’s room had several items of broken furniture. The person asked the manager several times during our visit when they would be getting new furniture. Another person had damaged their personal belongings and had not been supported to remove broken items or make the room safe prior to sleeping in the room overnight.

The manager had not recognised any issues within the environment. There were several potential risks such as broken football goal posts in the garden, a broken toilet, items obstructing the external fire escape, broken furniture and a lack of security at the service. A senior carer said they had made the provider aware of environmental issues that need to be improved but had not been supported to do so.

We observed the environment to be unsafe. Aspects of the home, equipment and furniture increased the risk of harm to people. We found fire alarms on the external fire escape on the 1st floor were not working. There was a risk that people who had restrictions in place would be able to leave the service without staff being alerted. There were items such as an old mattress in the landing of the fire escape causing both an obstruction and a fire hazard. We observed damaged furniture in people’s bedrooms, such as wardrobes, bookcases, radiator covers and curtain rails. As well as radiator covers that were not securely fixed to the wall. Blinds in both bathrooms and bedrooms were damaged and did not provide people with privacy and dignity. There was a lack of care taken in the environment of the service to protect people from harm.

The management team and provider failed to have sufficient systems to check the service was in good repair. Staff and managers told us that the service was secure as there was a sign on the door asking visitors to wait for staff to respond before entering. However, in practice people living at the service welcome visitors at the door and let them into the service. When we arrived, we were waiting several minutes whilst also shouting hello before staff arrived. The provider told us that monthly in-house audits were an expectation of the manager and that the former manager had failed to carry out these audits. We were also told that the provider has appointed a new role of audit and documentation manager, who will support managers at their services in the future. However, at the time of the assessment the provider had not taken responsibility for ensuring these audits were completed. The provider admitted they failed to act on concerns when they had been raised.

We were not assured that people at the service received their contracted 1.1 hours. People’s distress, agitation and aggression had increased over several months and with the lack of support to manage this they put both themselves and overs at risk. Ratios of staff supporting people when out in the community were not effectively managed. Of the 5 people who were supported to go to the beach, by 2 staff members, 1 needed to have 1.1 support when in the community this meant that the other staff member was supporting 4 people on their own. Staff did not always have the skills needed to support people with specific medical conditions. as they had not completed all the relevant training to administer a medicine in an emergency. Only 1 staff member in the whole staff team had completed all of the training to support the person should they need their seizure recovery medicine.

The manager at the service told us that we would be able to find which staff members were allocated to peoples 1.1’s from the staff rota however this was not the case. They advised us of the number of staff both they and the provider felt was needed to manage the service. However, they were not able to show us a dependency tool or how they had concluded that many staff would be sufficient to support the needs of the people living at the service. We asked the manager about the staffing levels. During the day that we visited the service there were occasions when staff had to leave the service for personal appointments. There had been no arrangements made to cover staffing during this time. In the afternoon another member of staff had to leave as they had an appointment, and this was covered by the manager. We asked the manager about the skill sets of the staff at the service. The manager said that they were not fully sure yet and needed to review this.

During our visit we found staffing levels to be insufficient, staff were not deployed to effectively support people to manage risk and keep people safe. The service was chaotic with people trying to gain staff attention. We observed staff managing incidents ineffectively. We saw 1 staff member using their size and body to block a person’s way when they were distressed. The staff member was observed not to talk to the person at this time which could have helped to deescalate the situation. We observed staff to be unprofessional in the way they spoke to people at the service, to each other and about each other. Staff did not always treat people with dignity and respect when talking to them. We heard 1 staff member say, “What is that all over your trousers already, what have you done.” Another staff member used nicknames for people that could be perceived as childish and demeaning and were not in their care records as a chosen or preferred name.

The provider had failed to implement sufficient training and competency checks to ensure all staff had the skills, knowledge and competence to provide safe care. Training records showed not all staff had received the training they needed to provide safe care. The provider told us that they had periodic service reviews to ensure correct staffing in both numbers and deployment. However, despite the number of incidents at the service having increased due to people at the service experiencing increased levels of distress, agitation and aggression we could not find any review or changes made to staffing numbers. The provider ensured that they completed Disclosure and Barring Service (DBS) at the start of a staff members employment. However, they had chosen to employ staff when the DBS showed there were criminal records. Risk assessments were in place for staff with criminal records. However, there was no process for reviewing these risk assessments or for reviewing DBS records. This placed people at risk of being supported by staff that were not fit to work with vulnerable people.

People were not supported to keep their environment clean and free from infection control risks. One person had bedding that was stained with bodily fluids. The pillow was replaced when we brought this to staff attention.

A senior carer said there had not been a cleaner at the service for a long time.

We observed communal bathrooms to be unclean. We found mould on ceilings, walls and where there were gaps between the flooring and walls.

Staff and managers did not follow the providers policy around infection prevention and control. This placed people at risk of infection.

We observed, a person who had been welcoming towards us in the morning presenting in the afternoon as sleepy and lethargic. A senior carer alerted us as they felt the person was presenting as if they had received an as and when (PRN) medicine that was prescribed to support the person when they were feeling distressed or agitated. There was no documented evidence of the person presenting as distressed or agitated or if they had been given the PRN medicine. However, the person was able to tell us that they had been given their head tablet which is known to be what they referred to as their PRN medicine. We reviewed the persons medicines records and counted the medicines that were in the service medicines cupboard for the person. There were 2 tablets that were unaccounted for. Following the assessment the provider said that they were investigating the missing medicines. There was a risk of chemical restraint being used at the service.

We received mixed feedback from staff regarding the missing medicines. A senior carer said that they had been told to administer the PRN medicine for 4 days following an incident where the person had been distressed. They said that they had refused to do so as the person was no longer showing signs of distress. Other staff state that they were told to monitor the person for signs of distress and that they were to administer PRN if needed. None of the staff could account for the medicine being missing. All staff denied administering the missing tablets.

Medicines at the service were not managed well. Staff and managers did not follow the providers procedures for medicine management. Staff members who were not trained to do so were allocated responsibility for medicines. putting people at risk of not receiving their medicines safely. The providers processes for administering as and when medicines (PRN) were not adhered to. This led to there being PRN medicines missing when we reviewed medicines onsite.