Archived: Westwinds - Care Home Learning Disabilities

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 identified three breaches of the legal regulations. Risks associated with people’s care were not managed safely by staff. Staff had not followed instructions from the speech and language therapist (SaLT) which meant people were at increased risk of choking. We observed people being assisted to eat whilst they were laying in bed, people being given meals of the incorrect consistency of food, falls risks not being managed by staff, and staff did not recognise coughing during mealtimes as a potential risk. There was a significant lack of planning and monitoring of evacuation equipment and we found an evacuation bag which did not contain any basic information about people despite the majority of people at the service being unable to communicate verbally. We found people’s call bells to call for help were out of reach, staffing levels at night time were insufficient based on the needs of people, medicines were not always managed safely, and staff did not always understand their roles and responsibilities in relation to safeguarding which meant they did not recognise the embedded institutionalised practices we observed. The principles of RSRCRC were not met as the model of care provided did not empower people to live their lives with maximum choice and control.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Relatives told us they felt people were generally safe living at the service but that they had raised issues in the past in relation to safety and these had not been addressed. They told us that different management teams had promised to address concerns in the past but that this had not materialised due to the inconsistency in leadership in the service. People were impacted by the lack of a positive learning culture at the service. For example, where we observed people coughing whilst being assisted to eat, staff did not understand that this may pose a risk to the person’s health and there was no culture of reflecting on staff practices to learn lessons and improve the care provided.

Staff we spoke with told us they did not regularly review incidents and accidents to look at lessons which could be learnt to reduce the risk of recurrence. Staff did not understand the principles of duty of candour and did not feel listened to when they raised concerns. The interim manager told us they were unable to instil a learning culture as their six-month contract was due to expire the day following our site visit. This meant that there was a lack of consistent leadership to embed an effective and positive learning culture amongst staff.

The provider’s systems in place to report, analyse and take action when incidents or accidents occurred were not effective in ensuring that there was a positive and proactive culture of safety. Whilst the provider had undertaken audits, these continued to identify similar issues to those we identified and there was insufficient action taken to address these. Quality assurance audits completed by the provider identified that incidents and accidents, such as injuries sustained by people, were not always reported appropriately to the local authority and we found that this was still the case. Following the inspection, the provider told us they had plans to implement a more robust system, but this requires time to become embedded in the service.

Relatives told us that people’s care was not always coordinated well across services and tailored to their individual needs. For example, where people had moved between services, staff did not always ensure these transitions were person-centred to ensure all needs could be met safely. Where a person required to attend a specific service to obtain accurate weights, staff did not ensure they were supported to the specialist service regularly. This meant there was a risk the person was experiencing weightloss which could impact on the efficacy of the equipment they required on a daily basis.

Staff told us they did not feel supported by the provider to ensure people were able to leave the premises safely. Where a person required to be weighed in a specialist facility, this was not being done due to a lack of transport. This meant staff could not assure themselves of the accurate weight of the person which was required to ensure their equipment was set to the correct settings. Staff were not aware of the risks to people in relation to transport arrangements at the service and staff told us they did not always involve people and their relatives to ensure their views were taken into account due to the lack of staff able to drive the service vehicle.

Partners working with the service told us they found it challenging to ensure staff were following guidance and instructions they had provided. Where healthcare professionals had provided instructions on how to support a person to be positioned appropriately during mealtimes, they found that this was not being followed by staff which increased the risk of aspiration. Another healthcare professional told us they had given staff instructions on mobility equipment and this was not being followed which increased the risk of developing pressure areas to the skin. We also identified these shortfalls during our assessment as these had not been adequately addressed to ensure people’s safety and continuity of care was a priority.

Whilst there was a business continuity plan in place to ensure the service could continue in the event of an emergency, this was not placed in locations where it could be accessible to staff. When we reviewed the fire emergency bag, we found that the business continuity plan and other information about people to ensure a safe transition were not present. This meant staff would not have had emergency contact details of relatives, suppliers and provider representatives if they had to evacuate the premises.

Relatives told us they felt people were generally safe living in the service at the time of the inspection but that there had been safeguarding concerns they reported in the past which had not been addressed in a timely manner. We saw people were exposed to institutionalised practices and had accepted these as they had become the routine. The people living at the service were unable to express themselves verbally but relatives told us people were doing the same activities each day and we saw people being encouraged to drink cold drinks when they asked for hot drinks because this was more convenient for staff.

Staff were not always aware of their role and responsibilities in relation to safeguarding. Whilst staff knew how to report concerns internally, 2 members of staff had a lack of understanding on why or how to raise concerns externally, such as with the local authority safeguarding team. Staff told us that there was a culture of acceptance in relation to institutionalised practices. The interim manager told us that while they were aware of this, they had to prioritise other areas in the service where they had identified shortfalls, such as recruitment.

We observed that institutionalised practices were embedded in the service and there was a culture of acceptance from staff and people. These practices included people having to wait for a certain time before they received their drinks and a lack of going out to the local community which meant people were isolated. We observed 1 person asking staff for a cup of coffee but a staff member persuaded the person to have a cold drink instead and meals were prepared in advance and left on the kitchen worktop until they were cold before they were given to people. People were not offered a drink with their meals and 1 member of staff was assisting 2 people to eat at the same time whilst having a loud conversation with another staff member where they discussed other people’s needs.

The provider had safeguarding and whistleblowing policies in place which were available for staff. However, several members of staff told us they did not have the time to read these and therefore were not aware of the contents. Daily notes confirmed that people were living in a service with an institutionalised, task-based culture as there was little access to the community available and people spent the majority of time in the service. Whilst this was also identified by the provider in October 2023 and previously, there was insufficient action taken to address this and we continued to find that this was the case during our assessment. Processes in place to ensure potential safeguarding concerns were shared with the local authority were not always followed by staff. There was a risk safeguarding incidents could not be investigated appropriately by relevant agencies.

Relatives told us they felt risks in relation to people were generally managed by staff but that they had not been informed of incidents or risks related to people’s care until they were contacted by the local authority. This meant that they were unaware of most risks and were not involved in managing these risks.

Staff did not always demonstrate an understanding of risks related to people’s care and how to manage these. Staff did not know how to prepare meals in line with guidance from healthcare professionals which increased the risk of choking. Staff were not aware of the risks of a potential head injury and staff did not understand how to ensure a person was monitored so their risk of falls could be reduced. When we spoke to staff and leaders about the management of other risks, such as weight loss and developing pressure areas, they did not understand the importance of ensuring that measurements were taken accurately so that appropriate action could be taken if there was a significant change.

We observed air-flow mattresses, which were in place to reduce the risk of developing pressure areas to the skin, were set to the incorrect settings whilst the person was in the bed which meant that they were not as effective. We observed staff were unsure how to manage a person’s risk of falls. The person’s care plans and risk assessments stated that they required monitoring at all times when they were walking but we found the person walking independently without supervision from staff throughout the day. Another person had sustained a wound to their head and staff did not take action to address possible causes such as the surrounding door of the waste bin which the person appeared to walk into repeatedly throughout the day. We observed people being offered and assisted with the incorrect consistency meals throughout the day which increased their risk of choking.

People’s care and clinical records included relevant information around their individual risks and what staff should do to support people to remain safe and well. However, we found that staff were not following these and managers had not addressed this consistently to ensure risks were managed effectively. For example, where a person’s care records stated that they required supervision when walking, we found the person walking independently without supervision throughout the day of our site visit. The systems in place by the provider were not effective in addressing these shortfalls. Care records and recorded instructions from healthcare professionals were not being followed by staff. Instructions included which consistency meals and drinks should be to reduce the risk of choking and how to manage pressure-relieving equipment.

People were living in a service which was in a poor state of repair which was not designed to meet all their needs. Equipment was not maintained well and the arrangements in place to ensure the safety and upkeep of the premises were not effective. We found that there was a culture of acceptance from people, their relatives and staff. This was not in line with the statutory guidance RSRCRC because the environment did not safely meet people’s needs.

Staff and managers did not understand their responsibilities to ensure that people were living in a service that was maintained well. They told us that concerns in relation to potential damp, other water damage to ceilings and old carpets were not addressed by the provider in a timely manner as these had been raised several months prior to our site visit.

We observed damage to the ceiling in a corridor, potential damp walls in one person’s bedroom, damaged wall panels, damaged furniture and carpets in poor condition. We identified that there were no hand rails in all corridors despite one person’s care records stating that they required to hold onto these. We observed the person holding onto other objects as they walked independently and this increased the risk of injury. We found equipment, such as air-flow mattresses, were not checked by staff regularly. One air-flow pump was set to the incorrect setting and another one had food residue on it. Staff lacked the equipment to weigh one person who required specific weighing scales and could therefore not be assured of the person’s current weight. We found cigarettes and lighters were accessible to people who were able to walk near the windowsill in the hallway, and the plant pot utilised as an ashtray immediately outside of the front door did not take into account the risk of fire as it did not contain sand or other fire-resistant materials to ensure cigarettes would extinguish fully. Throughout the day, we saw people walking unsupervised in the area where the cigarettes and lighters were kept. The provider addressed this when we made them aware.

Fire evacuation equipment was not adequate in the event of an emergency. We saw that the service’s emergency evacuation bag contained information on the names and number of people living at the service, but there were no contact details and there were no personal emergency evacuation plans. This meant there was a risk people would not be evacuated safely in the event of a fire. The local authority visited the service following our site visit and found that this had still not been completed fully. When we made the provider aware of the concerns we identified, they undertook a building survey which also highlighted concerns we identified. The building survey included a clear timeline and as a result one person was moved to another service until the damp issues in their room were remedied. Previous audits undertaken by the provider were not effective in ensuring shortfalls were consistently identified and addressed.

People had to wait for support as call bells were out of reach and this meant people who chose to remain in their rooms were calling out for help throughout the day. People who chose to sit in communal areas during the day were often left sitting in the room on their own without support. Relatives told us they felt there were sufficient staff at times but that a lack of staff at other times meant people were unable to access the community. This was not in line with the statutory guidance RSRCRC because people were not given the choice of accessing the community.

Staff told us that there were not always enough of them to ensure people could access the community. Staff told us they were expected to clean the premises, cook and provide people’s care. This meant that there were areas that were not always addressed, such as cleaning which had an impact on the environment. The manager told us that the majority of people required two staff members for assistance during an emergency. This meant there were not sufficient staff deployed at nighttime to ensure the safety of all people. They told us that this had been raised with representatives of the provider but no action was taken in response.

There were sufficient staff available to support people on the day of the site visit, however we found that staff had not always been deployed effectively as we alerted staff several times of a person calling out for help. The leadership of the service did not ensure staff were regularly checking on people’s welfare. We observed that there were no activities outside of the service and very few meaningful activities were being undertaken with people inside the service. We were told that this was because there was no member of staff on shift who was able to drive the service vehicle. When a staff member who was able to drive the vehicle arrived in the afternoon, they told us they were unable to support people to go out because they were in charge of the shift and therefore required to remain inside the premises. This was not in line with the statutory guidance RSRCRC because people were not able to take part in activities in their chosen communities.

The manager had not reviewed staffing levels to ensure there were consistently adequate numbers of staff in the home. There were 2 people who required to be repositioned regularly by 2 members of staff at night time, however there were only 2 staff working at night. This meant that there were no other staff members available to attend to other people should they require assistance. Staff training had improved in recent months prior to the site visit but this training was not effective in providing staff with the skills required to support people appropriately. Staff competency checks were completed for the majority of staff but these did not address the issues we identified in relation to how staff interacted with people and how risks in relation to people’s care were managed. New staff were recruited safely and appropriate recruitment checks were completed. We saw staff had completed and were signed off for their induction training.

People were exposed to poor infection prevention and control practices and there was a malodour present throughout the premises.

Staff had accepted that there was malodour throughout the premises. They told us that they could not always prioritise cleaning as they were engaged with people. Staff told us they regularly cleaned surfaces but that they had raised concerns around the malodour with the provider and that this had not been actioned.

There was a malodour present throughout the premises and the furniture in the service looked worn which meant it could not be cleaned properly. We observed staff wiping the kitchen worktop using a cloth and then placing the cloth adjacent to a person’s meal.

The provider had policies, procedures and resources for staff around infection prevention and control and management of infectious diseases. However, these were not followed by management and staff, and there was a strong smell present in some areas. Staff roles and responsibilities around infection prevention and control were unclear which meant staff did not always know which areas to prioritise. Following our site visit, the provider conducted a building survey which also highlighted malodour and a plan to address this by deep-cleaning the carpets and eventually replacing them.

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

Staff were not aware of the need to dial 999 if a person prescribed an oral anticoagulant (a medicine that helps prevent blood clots) suffered a head injury, and they were not aware of the health and safety risks associated with two medicines which were prescribed to people. Staff were not aware of instructions from healthcare professionals when measuring powder to thicken people’s drinks in order to reduce the risk of aspiration.

Medicines were not always managed safely. We found ‘when required’ and variable dose medicines did not always include a personalised protocol to inform staff when to administer the medicines and what to look out for based on the individual’s needs. We found ‘when required’ protocols for one specific medicine were all very similar and were not personalised. The protocols failed to highlight people’s individual ways of expressing pain and what staff should look out for. This increased the risk of people not receiving their medicine when they needed this. We also observed staff measuring the fluid thickening powder, which was prescribed to thicken fluids to reduce the risk of aspiration, was not consistently administered in an accurate way. We observed staff filling the measuring spoon, but they failed to ensure the powder was levelled before it was added to fluids. This meant staff could not be assured that the fluids have been consistently thickened in line with the guidance from healthcare professionals. Staff had not always completed competency checks to ensure they had the skills required to administer medicines in line with the provider’s policy. The local authority quality assurance team told us on 17 January 2024 that this had still not been completed and that day and night staff medicines training was out of date.