West Lodge Care Home

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. The scores for these areas have been combined with scores based on the rating from the last inspection, which was requires improvement. The assessment of these areas indicated areas of concern since the last inspection, our rating for the key question has changed to Inadequate. Staff did not always understand their duty to protect people from abuse. Management had not always ensured records were completed when an incident had occurred. When concerns had been raised, managers had not always reported these promptly to the relevant agency to make sure timely action was taken to safeguard people from further risk. Safety risks to people were not managed well. Managers had not assessed and reviewed safety risks to people and had not made sure people, and those important to them, were involved in making decisions about how they wished to be supported to stay safe. There were not enough staff to support people with their needs. Managers did not have effective systems to review staffing levels to make sure there were always enough suitably skilled and experienced staff on duty. Staff had not received relevant training to meet the range of people’s needs at the service. Staff received support through supervision and appraisal to support their continuous learning and improve their working practice. Managers made sure recruitment checks were undertaken on all staff to ensure only those individuals that were deemed suitable and fit, would be employed to support people at the service. We have taken action and asked the provider to make improvement.

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 unable to explain how the learning culture affected their experience in the service. However, due to the providers ineffective processes and systems, we assessed that people had a negative experience regarding a learning culture. When an incident of harm had occurred, the provider failed to ensure all safety events were investigated and reported thoroughly in a timely manner. For example, we found a person had sustained a burn to their skin and there was no incident record completed, investigation or any lessons learnt.

The registered manager was unable to explain how people, staff and management were involved in learning from incidents to ensure lessons are learnt. Staff told us that they had regular contact with the management team to review what was working well, and what could be improved at the service. However, there were no records in place to demonstrate what improvements had been made. Staff gave examples of how the staff team had learnt from incidents. For example, one staff member said, “the management explain to all staff during handover of any changes made to support our residents better.”

The provider did not have effective processes to review incidents and then make improvements. Staff were not provided with the opportunity to reflect after incidents, to ensure learning and improvement could occur. During the assessment, we identified that not all incident reports, records and auditing of accidents and incidents had been completed. Incident reports that had been completed were not detailed and did not highlight actions taken and lessons learnt. We found where a person had come to harm from a burn there was no incident form or lessons learnt to prevent the incident re occurring. This meant people were at continued risk of harm. 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. We reviewed incidents records however, the records demonstrate the duty of candour was not always followed.

People's experience of safe transitions was negative. People’s needs were not always appropriately assessed. We found an in-depth initial assessment was not carried out before a person made a transition to live at West Lodge Care Home. This meant a person was placed at the care home where their needs could not always be met.

The registered manager told us they completed people’s initial admission assessments over the telephone and people's needs were not always thoroughly assessed. Since our visit, the provider has told us they have amended their approach and now complete face to face initial assessments to ensure they are correctly assessing peoples needs. The registered manager had good knowledge of which health and social care professionals supported which people. Staff were able to explain when these professionals visited, and what type of support they offered. The management team knew how to monitor people’s health conditions, to ensure timely referrals were made to other services. For example, when a person had concerning weight loss, the registered manager made contact with relevant health professionals to obtain health advice and guidance.

We received mixed feedback from partners. A health professional had raised with other partner agencies that the provider had not ensured they always consulted a health professional in a timely way, and this had impacted negatively on people’s health. Other professionals told us the provider did contact them to ensure they obtained advice in the timely manner.

The provider did not have a process to ensure people were fully involved in their assessments, care planning and reviews where possible. Where people could not be involved in their assessment there was not process in place for family, where appropriate, to be involved. This meant there was a risk peoples information, wishes and care needs were not accurate. The provider did have a process in place to contact other health professionals regarding a persons care and support needs if needed.

We received mixed feedback regarding if people felt safe. One person told us, “I feel safe. Nothing to be afraid of. They’re very good.” However, one person told us, “Care Home is not suited to everybody. People with high level of distress behaviour shouldn’t be mixed in. [Person] gets hyperactive. [Person] fights anybody. I don’t feel safe anymore.” “There’s one person threatening me. I think he shouldn’t be mixing with people.”

Staff could explain their safeguarding process. However, we were not assured staff always followed their processes. We found an incident of harm that had not been recorded as an incident, or shared with the local authority safeguarding team.

We observed people were not always protected from the risk of harm when staff undertook manual handling practices. For example, we observed a staff member, and a visitor put their hands underneath a person’s armpit to try and support them to sit back on a chair. This placed the person at risk of injury from staff using unsafe handling techniques. It was also not appropriate for a visitor to be supporting people with moving and handling or laying their hands on a person. We fed this back to the manager who responded immediately and took appropriate action.

The provider did not have robust safeguarding systems and processes. We found not all incident reports, records and auditing of accidents and incidents had been completed. One person had sustained a burn to their groin area. We found no incident record had been completed. Daily care records did not detail the incident and actions taken post incident. The registered manager completed the incident form when we were onsite, despite the incident occurring 38 days before our visit. Incident reports that had been completed were not detailed and did not highlight actions taken and lessons learnt; this was shared with the provider. The provider told us they had implemented a new incident template to improve record keeping and that management would be reviewing the records to ensure more detailed recording. The proivder also told us they would review the process to allow for audits to identify patterns, trends and for lessons learnt. However, when we returned on day 2 of our visit, we continued to find poor recording keeping of incidents and accidents. We found 5 incidents and/or accidents had occurred since day 1 of our assessment. All of the incidents were recorded on the previous template and the records continued to lack accurate detail. The registered manager told us they had not had time to use the new template. All 5 incident records lacked information of whether an injury had occurred, no post incident observations, no detail regarding the time and date when health professional advice was obtained and when notifications were sent to the local authority or CQC. Without this detail, we were not assured safeguarding incidents were managed in a safe and timely manner.

People were not involved in their risk management plans that were in place. People or people’s relatives were not aware if a care plan was in place. One relative told us their loved one was on end-of-life care and had not been involved in any care plans regarding their end of life care. One person told us, “ I don’t know if everybody knows me."

A person who required support with Positive Behaviour Support did not have appropriate care and support to reduce incidents of distressed and/or agitated behaviour. For example, the person had identified and known behaviour risks, but management and staff could not explain what measures had been put into place to keep the person and other people safe. This meant there was no appropriate risk management plan in place to mitigate or reduce known risks.

We saw people were not supported safely. We observed staff were not clear on the early warning signs to ensure positive intervention could take place. The person showed distressed behaviour repeatedly due to not having the right and appropriate support from staff. We observed staff were not able to manage the behaviour or using deescalating strategies. The person went for long periods of time distressed and agitated. This meant people were at risk of deteriorating mental wellbeing in the absence of positive interactions with staff.

People’s needs were not clearly documented in their care plans, so staff did not have clear guidance on a person’s mental, physical, and social needs. Staff did not know how to support people to manage risk. We found a person to have a large purple bruise to their left eye. We reviewed the incident and accidents records, daily records, care plans and found no record as to how the bruise had occurred. The registered manager told us this was from a fall incident that occurred on the 5 October 2024. None of the 9 days records since the incident, including care plans, risk assessment, incident form, daily logs included any record of the bruise. No body map was completed in line with the providers policy to provide information if the injury was getting better or worse. Staff did not keep clear records on how they had supported people and at what time. For example, one person we found a photo of a pressure wound that had healed. However, there was no care plan, risk assessment, incident form completed to demonstrate a wound had occurred. The person's care plan was not accurate or reflective and had not provided staff with clear guidance regarding their risks in their skin integrity care plan. This meant that details were not in place for staff on how they should monitor the persons skin integrity, and when to request further support. Where incidents had occurred, there was no system and process to provide staff and people opportunities to review what had happened and ensure measures were put in place to prevent re-occurrence.

People did not always experience safe environments. We found the health and safety of the environment was not always kept to the standard to keep people safe. This meant people were at risk of harm.

The management team described a clear process for monitoring the safety of the environment. For example, the registered manager told us they completed regular checks around the building and explained how they passed concerns to the maintenance staff members to resolve. We saw that any areas they had picked up, had not always been resolved to keep people safe. For example, the manager had told the staff team to ensure doors that required to be locked for peoples safety should be locked. However, we saw doors were left open. The boiler door was left open and the pipes were hot. This meant people were at risk of burns from the pipes. Staff knew how to monitor the safety of the environment, and where to report any maintenance concerns too.

We observed fire doors were wedged open. For example, a person’s bedroom door was wedged open using their footstool to keep the fire door open and a small lounge had a chair used to wedge the door open. This meant people were at risk of harm from fire due to poor implementation of fire prevention practices. Furthermore, we observed that communal fire doors and bedroom doors that were fire doors did not close properly and left a significant gap. This posed a significant risk to people and staff in the event of a fire. We found hazardous products, including aerosol cans of air fresheners and shaving foam left in toilets and on PPE stations in the corridors. This placed people at risk of harm if they had access to these products and ingested them. We found a wooden wardrobe in a person’s bedroom that was not fully attached to the wall. This wardrobe could be pulled off and fall on a person causing serious harm.

We found healthy and safety checks that were in place were not robust, there was not a clear oversight of the safety of the environment, and this was confirmed through observations we found during both days of our onsite assessment. Health and safety checks had been completed. A water risk assessment had been completed to reduce the risk of water-borne bacteria like legionella. The assessment identified high risk actions, and some actions had not been completed. The registered manager told us they were obtaining quotes. The gas heating system was regularly serviced to prevent harm to people. People had access to call bells to call for support if needed

People told us there were not enough staff, and any needs were not responded to quickly. People’s comments were, “You have to wait a bit if they are helping someone else.” “can wait a long time for the buzzer to be answered at night and staff are not happy when he presses his buzzer.”

The registered manager told us they were using a staffing calculator to determine staffing numbers. We reviewed the staffing dependency tool and found it was inaccurate. We found they had calculated 4 medium dependency service users for 3 hours care a day. However, the record showed there were 5. This meant the staffing calculation was short of 3 hours. Furthermore, the dependency tool showed a person as high needs requiring 4 hours of staff care and support. However, this was incorrect, our observations on the 1 October and the person’s daily note records showed they required more than 4 hours support a day. Staff told us they had regular opportunities to meet their manager on a one-to-one basis for supervision. These meetings gave them the opportunity to feedback about their experiences and request further guidance or training if needed.

We observed staff using unsafe moving and handling techniques throughout the onsite assessment. For example, we observed a person distressed and two staff members used a block restraint over doors to stop the person from entering a room, meaning the person was not able to enter areas of the home. A further incident happened when the person wanted to enter a lounge and was distressed when they were told no. The staff member used pull techniques with their hands and arms to pull them out the living room in front of the inspection team. Furthermore, the registered manager told us the person is having repeated bruising on their skin and having medical tests for this. However, due to our observations, we were not assured this was not from poor and inadequate moving and handling techniques used by staff because staff were unable to support the person using positive behaviour support techniques. We observed the top floor to be unsupervised for prolong periods of time with people in their bedrooms who did not have access to the door codes to have the freedom to move around the service. The registered manager told us service users were on hourly checks, during this time no staff were on the floor. This meant people would need to wait to know if someone was safe or required support, because not all people could use a call bell. This placed people at risk of neglect.

There was not a clear process to ensure there were enough staff. The provider had used a calculation tool to assess how many staff were needed to meet people’s needs. However, the tool was not completed correctly and did not provide sufficient information how people’s staffing hours were calculated. Staff were not appropriately trained or competent to ensure people were receiving safe care. We observed that staff had used inappropriate moving and handling techniques and did not always use positive behaviour training to support people appropriately. Safe recruitment processes were followed. For example, previous employers were contacted to give references on the staff member. Staff had also 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. The service employed nurses. These nurses were registered with the regulatory body (The nursing and midwifery council). The management team completed regular checks to ensure their nursing registration was maintained.

People were at risk of infection due to poor management of infection prevention and control. High risk foods that had been open did not have an open date recorded. This meant there was a risk people were provided with food that was passed its used by date. Furthermore, there was no recorded hot temperature of the meat that was served for lunch to ensure the meat had been cooked appropriately and safe to eat.

Staff had received food hygiene training; they were able to explain what actions they took to reduce the risk of food borne infections. However, we found kitchen staff had not followed their training because we found the kitchen was not clean in line with infection prevention standards. The provider did take action and on the second day of our visit we saw an improvement. Staff knew what personal protective equipment they should wear and when. Staff knew how to put on and remove this equipment, in a safe way. This protected people from the spread of infection.

We saw the kitchen was not managed in a hygienic way to ensure people did not get food borne infections. The fridge was visibly dirty, foods were not labelled with open and/or discard dates. Food brought in by families were not dated. Furthermore, we found oil in a fryer which was not clean, the cooker was not clean and tiles had visible dirt marks. We saw that staff had access to personal protective equipment (like gloves) throughout the home. This allowed them to support people in a hygienic way. We saw any dirt or spillages in the home were quickly resolved.

We observed the kitchen to be dirty and not kept in line with infection prevention and control guidance. The floor was dirty and had not been cleaned. There was no systems in place for when certain areas of the kitchen should be cleaned. There was a cleaning schedule in place to ensure all areas of the care home were covered in the cleaning process to ensure the environment was kept clean and hygienic. This meant people were protected people from the spread of infection. Staff had received training in infection control, protective equipment and how to keep people safe in the event of an infection outbreak.

People did not share any concerns regarding their medicines support. However, we found people did not experience safe medicines management. We found prescribed topical medication was not stored appropriately. We found topical medicines in people bedrooms not stored safely. People living with dementia were at risk as they could have easily accessed these medicines. This placed people at risk of harm from unsecure topical medications that could be ingested or used contrary to their purpose. Furthermore, we found prescribed topical medicines did not always have legible prescription label. This meant it was unclear who they were for and when to apply. This risked medicine not being used for the correct person and it not being effective in line with manufacturers usage guidelines.

Five people were prescribed Lansoprazole, this medicine needs to be given 30/60 minutes before food and drink. However, we found this medication was given at the same time as their other prescribed morning medicines. A staff member who was administering medicines told us they were not aware and unsure if food and drink had been given before administrating the medication. This meant there was a risk of the medicine not being effective and placing people at risk of harm.

We found serious shortfalls in the management of medications, placing service users at risk from unsafe administration of medications. Many handwritten medicine entries were not signed by two staff members to confirm the transcribing was correct. This practice increases the risk of errors and places people at risk of receiving their medicines in an unsafe way. Five people were prescribed Lansoprazole, this medicine needs to be given 30/60 minutes before food and drink. However, we found this medication was given at the same time as their other prescribed morning medicines. This meant that there was a risk of the medicine not being effective and placing people at risk of harm. A person was prescribed Zomorph for pain relief, which to be given every 12 hours. Staff failed to record the time the medicine was administered, this meant there was a risk of the person not receiving their medicines on time and ensuring the dose was 12 hours apart. This posed a significant risk in case of an emergency, no other staff would be alerted regarding time specific medicines. This placed people at risk of exacerbation of symptoms associated with Parkinson’s disease. Two people required staff support with insulin for their diabetes care. Staff had not followed best practice guidance because they had not recorded what time insulin was administered after checking blood sugar levels. Staff did not have any guidance on how to respond to a hypoglycemia or hyperglycemia reaction. This placed people at risk of not receiving appropriate support. 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. However, we were not assured staff were competent due to our observations.