Wellesley House Nursing Home Limited

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

Our rating for this key question remains requires improvement. We identified 2 breaches of the legal regulations. People did not always receive safe care as care plans and risk assessments were not always in place, up to date or followed. The lack of effective systems in place to monitor the care people received resulted in a lack of learning culture in the home. Safeguarding concerns were not always considered or investigated to ensure people were protected from potential abuse. There were concerns with the safety of the environment and some furniture posed an infection control risk. Medicines were not safely managed to ensure people were protected from the risk of harm. However, there were enough staff available for people, who were safely recruited.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives raised no concerns with the learning culture within the service.

Staff we spoke with, were unable to explain this process to us or state how they were involved with this. However, one of the leaders told us they changed practices and ways of working when things went wrong in the service to implement learning. They gave us examples of how they had done this when safeguarding incidents had occurred. When we shared examples of lack of learning from incidents in feedback with senior managers, they were unable to provide an explanation.

The systems in place were not effective in ensuring people were safe. When incidents had occurred, for example, falls, we saw these were recorded however there was no investigation or review to identify any learning. The provider or manager was not always aware of when incidents had occurred and was not able to provide an explanation for these. For example, when people had unexplained bruises, we could not always see that these incidents were monitored to ensure learning from them.

We received mixed feedback from people and relatives about their involvement with the admission process. One relative told us, “They’ve not asked me about any of my relations care, what they like and don’t like and what time they go to bed”. They went on to comment, “They can’t speak anymore now too. I have no idea how they communicate with my relation.” Other people told us they had been involved with this.

Leaders told us there were processes in place to ensure people were assessed before they started using the service. However, staff were not always aware of the assessment processes used at the service.

As part of this assessment, we asked for feedback from the local authority and the integrated care board. They told us they had recently visited Wellesley House Nursing Home Limited and found concerns about people’s safety. They had worked alongside the provider to develop an action plan that they were working towards. The concerns were in relation to the management of medicines, the diets people received and the environment.

There were not always care plans risk assessments or guidance for staff to follow. Care plans and risk assessments were not always update when changes occurred. It was not clear how people and those that were important to them were involved with the process. This placed people at risk of receiving unsafe and/or unsuitable care.

People and relatives raised no concerns about safety. Everyone was happy with the care they received and felt safe. One person said, “I feel safe here. It’s all good”.

Leaders were unable to explain why they had not taken action in relation to unexplained bruising as they were not always aware of the body maps that identified this. However. staff and leaders were aware of safeguarding procedures and the action to take if they felt people were at risk of potential harm. They told us they had received training and what action to take if they were concerned about someone.

During our site visit, we observed people were not supported to transfer using the correct moving and handling techniques. We also saw people were transferred using equipment they had not been assessed as safe to use. This placed people at risk of injury.

There were procedures to identify and report safeguarding concerns however these were not always followed. We saw a series of body maps where people had unexplained bruising. Leaders had not investigated these, and the incidents had not been reported as safeguarding concerns. After our inspection we received confirmation, that this had been investigated. When needed we saw Deprivation of Liberty Safeguards (DoLS) were in place for people, however we could not be assured these were up to date as care was not reviewed when changes occurred.

People and relatives raised no concerns with how risks were managed. One person said, “I can’t walk, they have to push me in the chair. To do this they put me in the hoist. I sit on my sling all day and then they use the straps on it to put me in the hoist and hook me to it. They do that every day to put me in bed. They lower me down onto the bed quite fast, I have the rails on my bed I can hold onto. I feel quite safe”.

Staff were not always aware of people’s risks and how to support people safely. Staff we spoke with told us they were not always aware of what was contained in some people’s care plans. When care plans were not in place they could not always tell us how to support people. For example, staff was unaware of how to support a person with their diabetic medicines.

During our site visit, we saw people were not always supported in line with their care plans or risk assessments. For example, 1 person transferred with the use of a standing aid they had not been assessed to use. Other people were not always safely transferred using safe moving and positioning techniques. This placed people at risk of harm.

The processes in place to manage identify, review and monitor risk were not effective. There was no effective systems in place to update, change or add care plans when people’s needs changed. There was no oversight in place to monitor and review incidents that occurred within the home. There were no audits in place that monitored the care and support people received.

People and relatives raised no concerns around the safety of the environment.

Leaders told us there was, “Nothing obvious” they were working on. They told us they had repaired and made changes to some areas in the home. This included installing new security cameras and a new entry system to the home.

We saw areas of the home that needed repair and were unsafe. This included exposed radiators in communal areas and there were no suitable window restrictors in place. We saw there were doors that had signage on stating they needed to remain locked, and we saw they were unlocked and propped open during our site visit. After our site visit, we received confirmation from the provider that our immediate concerns had been addressed.

The health and safety audit that had been completed had not identified the concerns with the environment. Therefore, the system in place to monitor health and safety and the environment in the home were not always effective.

We received mixed feedback on staffing. One person told us, “They are all very busy so not a lot of time to speak with me”. Another person told us, “I have a buzzer with me. If I press it, they come to me quickly. I’ve never been left too long at all. They always manage to get round, but you can tell sometimes they are a bit rushed for time. They still do everything though, just in a bit of a more rushed way”. A relative commented, “Most of the time there are enough of them. If there was ever a time when there was fewer, I would say it was a weekend.” Other people felt there were enough staff. One person told us, “There’s enough staff”. People and relatives raised no concerns around the knowledge and training of staff and felt they had the skills to support them safely.

Both staff and leaders felt there were enough staff available for people. However, leaders confirmed there were no systems or effective tools in place to work out how many staff were needed. Staff told us they had received training that helped support them to complete their job. They confirmed they had not received training in relation to supporting people with periods of emotional distress or when they had a learning disability.

We observed some staff did not always have the skills or knowledge to support people in a safe way. For example, staff did not support people to transfer safely by using the correct moving and handling techniques or equipment. We observed other people received support when they needed it. Staff were available throughout the home and for people in communal areas.

Although we saw there were enough staff in place during out site visit there was not an effective system in place to ensure there were consistently enough staff available for people, this placed people at risk of not receiving the support they needed. Staff received some training to ensure they had the skills and knowledge to support people. This included mandatory training and training that was specific to some people’s individual needs. We reviewed the training matrix, and this confirmed staff training was up to date. However, effective systems were not in place to ensure staff had received training in other relevant topics to enable them to provide safe care. This included staff not being trained in key areas including periods of emotional distress or when people they cared for had a learning disability. Staff had received the relevant pre-employment checks before they could start working in the home to ensure they were safe to do so.

People and relatives raised no concerns with infection control. One person said, “My room is nice. It’s cleaned every day. They make my bed for me and change my sheets everyday”.

Leaders and staff told us they had enough Personal Protective Equipment (PPE) available to them and training in IPC had been provided. Leaders told us they had been awarded a ‘gold award’ in an external IPC audit in August 2024.

We observed there was furniture in use in the home that was in a poor state of repair and ripped, this increased the risk of cross infection.

The internal infection control audit that had been completed had not identified the concerns with the furniture. Therefore, the system in place to monitor Infection control procedures in the home were not always effective.

People and relatives raised no concerns with how medicines were managed. One person said, “They wake me up at 6 to give me my medicine as I’m diabetic. I have insulin every morning. They don’t forget. The nurse gives me my medicines.”

Leaders told staff had received training and their competency was assessed to ensure they were safe to administer medicines to people. The manager confirmed there was no medicines audit currently being completed and this was due to commence the following week. We spoke with the staff member completing medicines, they could not confidently reassure us they understood the needs of the people they were supporting in relation to the medicines they administered.

We found concerns with how medicines were managed. We saw prescribed medicines were insecurely stored. When some people’s medicines had run out this had not been replenished in a timely manner and people had not received these medicines as prescribed. We found stock checks were inaccurate. This all-placed people at risk of harm. There was no medicines audit currently being complete that could identify these concerns.