Walshaw Hall

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

People told us they felt safe living at the service. Feedback from relatives confirmed they thought their loved ones were safe and individual needs were met by staff. A relative told us ‘I have peace of mind knowing that my relative is safe, I know I can rely on the staff’. We found that care plans appropriately documented risks and these were reviewed regularly. Staff were confident the manager would act on information and keep people safe. When speaking to staff, they were aware of people’s risks and how to manage them, including ensuring people received their medicines as prescribed. We received mixed feedback around staffing levels and some gaps in mandatory training. The newly appointed Registered Manager was aware of these concerns and was implementing new approaches at the time of the inspection.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they felt safe living at Walshaw Hall. Comments included "I sometimes get up In the night; I have a pressure mat so they know when I get out of bed. They will come and check on me because I can get myself up when I want. The night staff will come in and talk to me." Relatives were very positive about staff keeping people safe, with comments including, "I drop my relative back off and he just gives me a wave; that’s how I know he feels safe."

Staff confirmed they had effective systems in place such as handovers and they had access to people’s care records to enable them to be kept up to date on changes in people to minimise risks. A staff member commented ‘We have a handover every morning to go through any changes and concerns. We also do this at 2pm at staff changeover'. Staff commented how they felt communication between the team was good.

We observed how staff had developed positive relationships with people who they knew well. People appeared to be happy and relaxed in the presence of staff. For example, we observed a staff member offering emotional support to a person and talking to them about how they were feeling. The staff member gave reassurance in a kind and caring way. Staff members were observed using moving and handling equipment and did so safely, whilst treating the person with respect and dignity.

People’s care records included relevant information around their individual risks and what staff had to do to support people to remain safe and well. We found care plans contained risk assessments regarding falls, skin integrity and nutrition as examples. Records documented referrals to external healthcare professionals were made in a timely manner. We found some people had experienced delays with their care plan and risk assessment reviews taking place due to staffing issues. Frequency of reviews had improved since September 2023, but the service recognised there were more improvements to make. Some minor documentation issues were found with people’s repositioning records and were discussed at the time of the assessment with the management of the home.

People told us they felt the risks associated with their care were managed well by staff. One person told us ‘I have no worries here. We are safe, I have my frame and we can come and go as we please’. A relative told us ‘I know he feels safe here. He is not as anxious and doesn’t get upset the same’. People who lived at the home told us they have call bells and these make them feel safe in case of an emergency.

Staff confirmed they had effective systems in place such as handovers and they had access to people’s care records to enable them to be kept up to date on changes in people to minimise risks. A staff member commented ‘We have a handover every morning to go through any changes and concerns. We also do this at 2pm at staff changeover'. Staff commented how they felt communication between the team was good.

There was a relaxed atmosphere at Walshaw Hall and people appeared comfortable in the company of staff. During lunch, we observed a staff member recognising a person living at the home walking around in stockings. The staff member took action immediately and assisted the person to put appropriate footwear on. We observed people being given food and drink safely and according to their preferences.

People’s care records included relevant information around their individual risks and what staff had to do to support people to remain safe and well. We found care plans contained risk assessments regarding falls, skin integrity and nutrition, as examples. Records in place documented that referrals to external healthcare professionals were made in a timely manner. We found some people had experienced delays with their care plan and risk assessment reviews taking place due to staffing issues. Frequency of reviews had improved since September 2023, but the service still had some improvements to make. Some minor documentation issues were found with people’s repositioning records and were discussed at the time of the assessment with the management of the home.

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

We received mixed feedback from people about staffing levels. Everyone we spoke to was very complimentary of all the staff in the home and the care provided, with one person letting us know "They [staff] are excellent." However, some people made references to the use of agency staff. Two people had completed a recent survey and had provided feedback about some delays with staff responding to their call bell.

Staff told us of shortfalls in staffing levels and how sickness was an issue in the home, "We should have three staff and a senior, today [but] we only have two care staff due to sickness. This happens two to three times per week." On both days of the assessment unexpected staff sickness was an issue, and this was covered with the use of agency staff where possible. The home attempted to use the same agency staff for consistency, however, one staff member explained how the use of agency staff made their role more difficult. They told us that not all agency staff knew how to use the hand-held electronic recording devices used by staff. Staff described how care plan reviews could get delayed when staffing levels were lower, as senior carer assisted in providing care and support. We were told by some staff members that team morale was affected when staffing levels were lower than expected.

Our assessment took place over two dates, and on both dates we observed that the home was understaffed due to staff sickness. Staff were still responsive to people's needs, took time to talk to people and ensured people were comfortable. Staff were observed supporting people in a kind and considerate way.

Safe and effective recruitment practices were in place when employing staff. This included requesting and receiving references and checks with the disclosure and barring service (DBS). Staff training completion had not always been evidenced or monitored. Not all staff had completed training refreshers, meaning some skills had not been maintained. The newly appointed Registered Manager was aware of these issues and had a robust plan in place to drive improvement. At times, unplanned staff absences had caused issues with staffing levels in the home but had not negatively impacted people. The Registered Manager was aware of these issues, and let us know of the plans in place to drive recruitment, monitor staff absence and take appropriate action. On-call support was in place for out of hours and this worked effectively.

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

Feedback on medicines optimisation from people living at the home was limited. When asked about how staff help with medication, one person told us "They give them to me, day and night." This information was supported by a medication administration records (MAR) in place. Another person told us that they have remained independent and do not need the assistance of staff to apply their own prescribed cream.

Senior staff told us they had recently carried out medicine observations with staff. Staff told us, "We carry out weekly medicines audits. If we notice any errors, we will speak to the deputy manager and will redo medication competencies with staff." Another senior member of staff told us that medication was part of the home's monthly management meeting; these provided opportunities for senior staff to keep up to date with current medication topics within the home.

Some processes had been put in place for managing medicines safely, however, we did identify some areas of concern. Some manual cream charts had not always being completed. The home also held excess stock of medication, that needed to be returned to the pharmacy. We also reviewed the documentation the home held regarding use of covert medication. Authorisation had been obtained from the GP and paperwork was in place, however the use of covert medication was not easily identifiable on the paperwork in place. The management of the home told us they would be reviewing our findings. We did find that people received their medicines as prescribed and checks on staff administering medication were carried out by senior leaders.